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HomeMy WebLinkAbout98-0914 15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN '° ` Dept. 280601 ~, It q 8 : o o g ~ y Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth - , Decedents Last Name Suffix Decedents First Name MI c ~ r L~~C , f~ r~ ~V (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name MI .. ..;~C~.r..~-Y Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ! ~ Z ` ©' g8~8 ° REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return 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 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) between 12-31-91 and 1-1-95) (Attach Sch~ O) CORRESPONDENT -THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAT ON SHOULD BE DIRECTED T0: Name Daytime Telephone Number Firm Name (If Applicable) First line c,f address 1~. s~-~r~~ RoA.~ Second line of address City or Post Office State C~rr~~ N~~~ ~~~ ZIP Code REGIST~R OF WILLS USE ONLY r-a C7 c' gy ~~.:` © . p -~~- ~7 Q {r-.r [~ _.., ~. <:. - ~~ f\3 ~ ~, ~~ . _ i C.7 -~ C~''l r /7 /~ ' ' ~ f ' / o I ~ t' ~ c Correspondent's a-mail address: Under penalties of perjury, I declare that 1 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. SIGN RE OF PERSAN R~S~ANSI)~.E FOR FJLING RETURN SATE A ~ ,~ AD~ e,~s ~ 71 ~1 ~ ~ ~C1/t~{~ ~~~ ~,~ ~ "i b /~ SIGN ~ E OF PREP (yTHER THAN REPR Sj=,NTATIVE DATE j l ©~~ '~ USE ORIGINAL I Side 1 15056041046 150560141D46 J 15056042047 REV-1500 EX Decedent's Social Security Number J °~,t~3 o, Decedent's Name ~~ ~ ~ #_-~°• ~ =~ ~ ~°"` RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. , .,"S rf .C,tip..ti;. Tit 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ,V .as :., .: ~~~ ~~<.:. ~ O t e 3. Closely Held Corporation, Partnership.or Sole-Proprietorship (Schedule C) ... .. 3. ~,,e~~ *F ~ 4. Mortgages & Notes Receivable (Schedule D) ........................... .. ~ ,, 5. p PrtY( )...... Cash, Bank De osits & Miscellaneous Personal Pro a Schedule E 5. .. ~ ~ ., O U = Y r 6 Jointly Owned Property (Schedule F) OSeparate-Billing Requested ..... .. 6. ~ ;, {~ . 7. Inter-Vivos Transfers & Tiscellaneous Non-Probate Property ~ ~. :" , (Schedule G) C Separate Billing Requested...... .. 7. ~ ~ +~ , 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ Y ~ ~ ~ l H d 9 ~ 3 ~, 5 ~ F 9. ) .................. e u Funeral Expenses & Administrative Costs (Sche ... . , ~ ~,.- 10 S ; ..- ~ ~ ~ 0~ ~ ~' (~ " 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... . , 11 . L ~ ~ ~ 7 ~~~ 11. Total Deductions (total Lines 9 & 10) ...............:........:....... ... . _ ~ , J ~ d O 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. Nef Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ D ~ 0 C? 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 _ . 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 ~~~~~~ 15056042047 Side 2 ~« O U O 150560.42047 REV-1500 ~X Page 3 nrar_prlpnt'c Cemnlete Address: File Number Z r ., Qf Q.. DOOt f ~1 DECEDENT'S NAME STR ET ADDRESS 3.8 G' ar~ P. ~.. - - ---- - -.,--- - -- CITY ~ec ~hres 6~, ST TE I ZIP ~i¢ 7oS5 r Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit -_ B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1} O Total Credits (A + g + C) (2) Total InteresUPenalty (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 tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (56) fl Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPF~OPRIATE 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 ................................................................................................................... ...... ^ ^ 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? ....................................................................................................... " ....... ^ ^ or payable upon death bank account or security at his or her death? ....... 3. Did decedent own an "in trust for ....... Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 4 . contains a beneficiary designation? ................................................................................................................. ....... ^ 0 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 ar 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)(L3)]. 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. ~ pe~rssylva~~a - DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~C~i~~~f~E , RCA' ESYA~~ ESTATE OF FILE NUMBER w,ii~~, L, /ham C .~1,. ~ i-~~-~01 iy Afl real property.owned solely or as a tena in common must be reported.at fair market value. Fair market value is defint4d 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. If mare space is needed,..insert additional shzetr of the same size. REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT cq~~~/~cp~~ ~ e J 1 ~CI~J ~ ~3®~®J ESTATE OF FILE NUMBER Ali nrot~erty 9flintly-owned'with•wight of swrvivorship must be disclosed°nn Schedule F. .,- ilf.mocezspace.isneeded;insert.additional.sheets.of the same size) REV-1504 EX+ (6-98) ~~5~~~5 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~®~ C10SELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRlETORSi~IP ESTATE OF _ FILE NUMBER Schedule C,1,or C-2 (including all supporting informatkSn) must.he attached.for.eaph.closely-held corporation/partnership interest of, the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. t~l illui « SV4(:C ~p.11CC(1CU, Insect aaauonat sneeze. at the same s¢e) . REV-1505 EX+ (6-98~~~~~fi~ ~7 g v~ CLCISEl.Y HEL® C®RPC9RATE CON1W10NWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STC9CK ~~V~rOR~AT~C?P! REP®RT RESIDENT DECEDENT ESTATE OF Product/Service w~ 1 l~aM t,, M~C,,rJ~ zA-q~-cacti ~~/ 1. Name of'Corporation State of Incorporation Address ~' Date of Incorporation City 2. Federal Employer I.D. Number 3. Type of Business 4. FILE NUMBER Total Number of Shareholders Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VotinglNon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stocb;. 5. Was the decedent employed by the Corporation? ................................ ^ Ys:s ^ 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? ..... ^ Ye:s ^ No If yes, Cash Surrender Value $ Net proceeds payable $ _ Owner of the policy 8. Did the decedent sell or transfer 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 Attach a separate sheet for additional transfers andlor sales. Date 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? ............. ^ Ye:s ^ No If'yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of deathu and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair maii<et valuels: If real estate appraisals 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. State Zip Code. Consideration $ (If more space is needed, insert additional sheets of the same size) . REV-1506 EX+ (9-00) 1t° COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT '~~ PART~IERS!HiR ii~EC3R~ATiC~~ REPORT ESTATE OF FILE NUMBER 1. Name of Partnership / Date Business Commenced Address Business Reporting Year _ City 2. Federal Employer I.D. Number 3. Type of Business ProducUService State _ Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide init'sal investmervt $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amountnf.indebte.dness,.$. 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yves ^ No If yes, Cash Surrender Ualoe $" 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 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Ye;s ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Ye:s ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership,dissolved or liq.uidated,.after.the decedent's death? _ ...................^ Yes.. Q No. If yes, provide a breakdown of distributions received by the estate, induding dates and amounts received. 13. Was the decedent 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 elach interest. • s- • A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of finahcial 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 addresses and estimated fair market valueis. if real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (6-98) pg r~TT~~ ' COMMONWEALTH OF PENNSYLVANIA er,®1Ci VJ'i~EJ ~ ~~ E sS INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT __- - ESTATE OF FILE NUMBER Atl.oro.oertv.iaintlv~wned.with right of survivorship must be disclased on Schedule F. }f mor=..5paee,is~reeded, insert additional shsPts of the sameaize) REV-1508 EX+ (6-98) s COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~ CASH, BANK DEP®SITS, ~ o~1SC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Gn I ltcM L, M~ Cl~•d~ 2--4~-on9 ~~{ Include the proceet~s of.liti,gation andlhe.dale.the.p.mceeds,were received;by, the.estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If .more space. is.r+eeded~•.insert-•additional Sheets of lh a same.5ize),. REV-1509 EX+ (6-98) COMIv10NWEALTH OP PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER lf.an.assetwas made joint wit n Ane,year..of the decedent's date of death, it must be reported on Schiedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. B. , C. JOINTLY-OWNED PROPERTY: ~/~ ITEM NUMBER LETTEP. ~. FOR JOINT TENANT •-:~DAT°_• -~ MADE JOINT ~~~ DESCR!PTION:OF-PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR iDENT1FYWG NUMBER. ATTACH DEED FDR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUES OF ASSET ~°ro ~OF DECD'S INTEREST ~DATE~OFDEATH VALUE OF DECEDENT'S INTEREST 1. A. ' TOTAL (A1so enter on line 6, Recapitulation)~$ .;If ,mere Gp.oe is needed,. insert add'dionalsheets of the same size). -4 REV-1510 EX+ (6-98) CONiN10NWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ler~~ Ow INTER-VlVOS TRANSFERS & MISC. NON-PR08ATE PROPERTY FILE NUMBER This schedule must.be completed and led if the answer to any of questions 1 through 4 on the reuerse side of tile. REV-1500 OVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT ANO THE DATE OF TRANSFER,ATTAGHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'$ INTEREST'' EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. ~~ TOTAL (Also enter on line 7 Recapitulation) $ (If mpra space is.needed, insert additional sheets. of the.same size} REV-1511 EX+ (10-06) ~F ~~~~~ COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE tJUMBER Debts of decedent must be reported on Schedule.L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. ... 7 yoo . cx~ F„hftrAL' ~~/~/k~-~J ~IdSrDhL f y' ~Od •~d B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions /~~/, Name of.Perso.nal Reoresentative(sl /'~ t C V/ Street A/~d/d~ress f ~J~ i~ City / 1r ~., ~ 0. r. t [ a b ~ Y ( State Zip ~ ~ 0~1 ~+ Year(s) Commission Paid: +D dd .~0 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 U ,n 4. Probate Fees /~ e ~ d 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ ~3 d~,.l (tt more space.is needed,. insert additional sheets of She samesize) .. . ® p;?r~~sy~v~r~~~ DE?AR7MENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT a~~e~~i,9~~ aE6TS 6r DECEaE~fT, M®f~TGAGE LI~SILITIES ~ ~IE~lS ESTATE OF rte numrscn Report debis incurred by the decadent p for to death~that remained unpaid at the date of death, including unreimblurs@d medical expenses. If .rls1re sp~e= i~ needed, .insert.additianal sheets nf. the. same s~ze_ D j~~~ii'iSy~Of~i3~~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~~~~~~ E;c1V~FICFAR~ES ESTATE OF FILE IdUh1i3ER ~ _ ~d~g~y RELATIONSHIP Tt) DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRE55 OF PERS N(S) RECEIVING PROPERTY Do Not List Trustee(sj OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 {a) (1,2).] 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, MS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1 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. . REV-1514 EX+ (4-09) pennsy~var~~a ~EPAFTMENT OF REVENNE Bureau °f Individual Taxes PO Boxz8o6oi Harrisburg PA i7iz8-o6o> LIFE ESTATE, ANNUITY ~ TERM CERTAIN (CHECK BOX 4 ON REV-i5oo COVEA SHEET) ESTATE OF I /~ FILE NUMBER n This schedule should be used far all single-life., ioint 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 Departmf:nt of R'everpue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death frgm 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^', Other NAME OF LIFE"TENANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH ' TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life'or ^ Term of Years - ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life for ^ Term of Years 1. Value of fund from which life estate is payable .............. . ..........................$ 2. Actuarial factor per appropriate table ........................................ . ...... . Interest table:rate - ^ 3.5% ^ 6% .^ ,10°10 .^ Variable Rate 3. Value of life estate (Line 1 multiplied by tine 2) ....................................$ NAME OF LIFE ANNUITANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY I5 PAYABLE ^'Life ~r ^`Term ofYears ^ Life 4r ^ Term of Years ^ Life pr ^ 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-weekty..(26) ,,, ^, AAlonthly~ (.1.2) , ^ Quarterly (4) ^Serni-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 - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructior'IS.) ...............:•:...:.......................... . 7. Value of annuity - If using 3.5, 6, or 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 that create the above future interests must be reported as part of the estate assets on schedules A through G of the tax return. The resulting {ife or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space •is needed, use .additional. sheets.of. thesame size REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~e~~®~~~ i~ EUTt1RE 1~TEREST CC~f~PRC)~~SE (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER This Schedule is appropriate only f estates. of decedents. dying after 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. Beneficiaries 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 rightof withdrawa! 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: /V IV. Summary of Compromise Offer: 1. Amount of Futurelnterest ...........................................................$ 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 Line 1 passing to spouse at appropriate 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°J°, ^ 4.5% .............................$ (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 Lines 2 thru 6 must equal Line 1) .......................$ (If more space is needed, insert addfuonal sheets of the same size) REV-1649 EX+ (6-9B COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~t`ytP~~®~~~ ELECTION UNDER SEC.9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF ~ FILE NUMBER Do not complete this schedule unless a estate is making the election to tax assets under Section 9113(A) of the Inhekitance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for Bach trust. This election applies to the Trust (marir,al, residual A, B, By-pass,. Unified Credit, etc.). If a trust or similar arrangement 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 ttje election to have such trust or sim- itarproperty 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 sha11 be considered to have made°lhe election onlq 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, avhich Dass to the decedent's ....:r~,..,,.,.~.:,+::~; ~.,,:,:~w4r~;;~,,c,~;vnuuiuunaisneers or me.samQ Stzel .. ,- _ f~OTICE ,OF INHERITANCE TAX Pennsylvania ~ BUREAU OF INDIVIDUAL TAXES A'~'RR,A~IS~'MENfi; 54Y~~UWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION ;-:o~',,.D~~ucTl':OHS' AND ASSESSMENT OF TAX REV-1547 EX AFP C12-09) PO BOX 280601 ... ,; HARRISBURG PA 17128-0601 ~~~ ~~ ~~ ~~"~ ~~= ~}~ DATE 04-19-2010 ESTATE OF MCCURDY WILLIAM L ~~F~~ ~,~ DATE OF DEATH 10 - 05 - 1998 ~~~'~-!h~"~~`~:' ~~t ~^~- FILE NUMBER 21 98-0914 ~~,#`~~ '-~`~' ~ •!r '~ COUNTY CUMBERLAND PATSY L MCCURDY ~ `T- ~-~ ~ ~f~, ACN 101 12 SHADY RD APPEAL DATE: 06-18-2010 CAMP H I L L PA 17 011 (See reverse side under Objections) Amount Remitted- -~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ---- -~ R_ETA_IN LOWER POR_TION_ FOR YOUR RECORDS ~'- _ __ REV-1547 EX AFP C12-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: MCCURDY WILLIAM LFILE N0.:21 98-0914 ACN: 101 DATE: 04-19-2010 TAX RETURN WAS: CX] ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .0 0 NOTE• To ensure proper 2. Stocks and Bonds (Schedule B) C2) .0 0 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 1,0 0 0.0 0 submit the upper portion of this form with your 4. Mortgages/Notes Receivable (Schedule D) (4) .0 0 1:ax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 3,5 0 2.0 4 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G] (7) .0 0 8. Total Assets (8) _ 4.502.04 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9)__ 1_3.04.00 10. Debts/Mortgage Liabilities/Liens (Schedule I] C10]_ 15, 072.56 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflec t figures that include the total of ALL returns assessed to date ASSESSMENT OF TAX: . 15. Amount of Line 14 at Spousal rate C15] .0 0 X 0 0 = .0 0 16. Amount of Line 14 taxable at Lineal/Class A rate C16] 0 0 X 0 6 = 17 A _ .0 0 . mount of Line 14 at Sibling rate C17] 0 0 X 0 0 = . .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 15 = .0 0 19. Principal Tax Due TAX CREDITS C19)= - .0 0 : PAYMENT RECEIPT DISCOUNT C+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. a ~~~ 1 cll] 28, 117.56 c12] 23, 615.52- c13] _ . 00 c14) 23, 615.52- -.,,, _ ~,~_ ,,,~_ ,,~~ Pennsylvania ~ BUREAU OF INDIVIDUAL TAXES - {T :I-I~H.~.~TANCE TAX DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION ;;;~~,~~;. '' REV-1607 EX AFP C12-09) Po BOX 280601 '" Sit~'~EM•EI+1T OF ACCOUNT HARRISBURG PA 17128-0601 ~~~ ~~ ~3 P~ ~~' ~#2 DATE 04-19-2010 ESTATE OF MCCURDY WILLIAM L ~~E~~~~~ DATE OF DEATH 10 - 05-1998 (~R~;--~~,,~~';J ~'n! J~.~? FILE NUMBER 21 98-0914 (;(;~ '!= ~ 4 ~t ~_ `~~ Pw, COUNTY CUMBERLAND PATSY L MCCURDY ACN 101 12 SHADY RD Amount Remitted CAMP HILL PA 17011 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ~ ~~~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ H ~~~~~/~~~~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~ ^ REV-1607 EX AFP C12-09) *** INHERITANCE TAX STATEMENT OF ACCOUNT *** ESTATE OF:M000RDY WILLIAM L FILE NO.: 21 98-0914 ACN: 101 DATE: 04-19-2010 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-12-2010 PRINCIPAL TAX DUE: .00 PAYMENTS CTAX CREDITS): PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~~