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HomeMy WebLinkAbout10-21-09 15056051047 '~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Countv Code Y?ar File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN •~ G~ l ~ ~ ~7 ~ 7 ! S Harrisbur , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth b S~ I `~ ~ ~,~~ (~5 ~1 l ~.0 04 d ~ ~S 19 t 7 Decedent's Last Name '~uffi;~ Decedent's Firs t Name MI ~~ ~.v ikA s r~~ ~+~ ~ I''I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t~ 1. Original 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) ~ 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 BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 'DO L.O REs l-~-©$ RLE -1 [ ? 7(06 (~ 73 Firm Name (If Applicable) First line of address a3 K~L~ ~ Second line of address City or Post Office L~(.~L_I S LE State P d~ ZIP Code REGISTER(Of WILLS USE`r,~ `-. (-~ ~ `t:7 _~ ( ~ +:~ ---4 -'?? µ~ N :.,:_~ -- <;., ~1TE FILED C7 C!Y l ~ © t sq o© 3 ; ~t ~;~7 '~:~ ~ ~;~ ~:: C7 ;~,, '~ a t'i r r~ ,, 7"', ~-' Correspondent's a-mail address: ~1/'~ p6 I'` ~ ~ ~ Q O ~ , C:~rY1 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. SIGNAT OF P RSON RESPO IB E FOR FILING RETURN ATE ,~ ~ ~`~ ~ . o _ ,n ,~~-_ o „ . ~ 2 oaf' ADDRESS oZ 3 ~p ~~i Ur^ • ~a r ltS ~P , Pl~ l ~10 I S = cJ00 / SIGNATURE OF PREPARER O HER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 15056051047 ~D EZ ~ ~ ~ Side 1 15056051047 REV-1500 EX 15056052048 Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. Decedent's Social Security Number p .5'0 ~ ~ 12 S 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. ~ ~ 'f ~~ • ~p~ 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. 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. ~' ~ ~D Z ~ 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. C ~j ~ J 11. Total Deductions (total Lines 9 ~ 10) ................................ ... 11. ~ ~ ~ ,j ~ ~ ,~j c~c. 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. - ~ ~ Q ~ . ~~ 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. '~ ~ + ~ ~. 6 ~.7 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. « D ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15D56052048 REV-1500 EX Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) ~o.vo Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) d ~ ~ (~ 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 ................................................................................................................... ....... ^ d. receive the promise for fife 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 "intrust for" or payable upon death bank account or security at his ar her death? ....... ....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................. .................................................................... ^ ....... ~) 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 Jufy 1,1994 and before January 1, 1995, the tax rate imposed an the net value of transfers to or far 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 Jufy 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 ar 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}]. 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. acv-,soe Ex. I+-sn COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointlyowned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ ire Paid ~u~ne ral ,~cco~ n-} ~h©ce~s ~I.S Pr~Qid '~int~~e~ j Trl~s 1Cund. Po !3 o k L ~~ih~~kan, ~T o8'73~ ~~ ~0~'~~~~ S0. / 1 n~qs ~q n oZ 3 g" Cl-, ~s~ nN ~ S~r~ e7L Acc-~ .~ 3 Zao t~3 ~ _-- ~ ~ e-~~< i n~ A-LC.o u n~ !v, 018', ~3 x`731, z~ TOTAL (Also enter on line 5, Recapitulation) I S ~ o~ 7 ~ Cf , ~0 7 (If more space is needed, insert additional sheets of the same size) r~-- ~ iv b~se~xu~.se _ _ _ ~~ ~~ ~l~Z~lr'~~ / t~~~ ~ G~~p GeefcetaANam~eGanminer. X . , i j <. . 6351Yortli l4Lopc~Av~e~re• ki~cte~~ Ne±et:;lereey.07+0©16 . ~ ~/ ~' ~' ~ ~ s ~~o ...•~ ............:..........._.. TelepMne ~18148B-4~ 18+Fax (9t~6j 486-7229 • •` t _ T3~ps of Mal~a1 . Joseph J. slaaa Merl' Ju11on:$1~ i'~Irec~or Ytlerlot #teieFial C.~E nu Lloerwe No. 9Ptd NJtJaenagNo.36~1~9 Irichael G. Adis, OYraobi vauR~7rle~Brrisf G1[tnfair~er _. I+u ~iaerosFro: 3988 ~11m11BhNKlrber ..............................._.. ~, Madei ~~ ~ ~ofMaiatiel b+'K""~~c-~a~,y«».+~t C1A~n.dwp~w nFlt~prro~pdj., tJa- {eof,lrrara~nq ........... ~aRMATION ON UEC'EASBD- ct°u'n~........... ,., _..._.. ....._ G~rds; 7G+ o~ P~ e ~ .........:... r Y Per10Q~~ } ...._~.. ....._...~a...°L?..._.. i~-L.-~ Par Bast( , , p 0 ,l. . . ...._.. L~ RepfeterBook . ....... ... ._ _ N ~ ..... _ .....~_........ l7~Me : ,E~~1s d Engraved Nemepn~ for C.eslaet :;: ....~ ~+ef terns of A~ercttansiise t~ . '- . , e~} ........:......:: :».. & _ . ~ !.^~ ~ b ......................... c. ~TA1'~~KT ~ S'~l.EC'fTD ~~ ~~~aerho~d~~iara e~~ere ar a #ws~ ea ~tai+ah ~r.t-tKe~t~rasQFS ror~u.r~v~~a~a., # 6r~.3 ~ ~ .... q e ~ _.. ~ Y. C1~SH UIS8~5t'B emetie~yor~rrwMary..,.._._.._ .....:........_.....,.~... ... _. ~. ~-FS~ ' C'~ L PKUFB~ONALSERVI4'SS _ , K ~.: ~BY4u+ah..... .... . .. ...... ~ go. ~v Setwbes Of funeral t#Liel.'lorandSle~...,....m....._. . ~..._.la~.:.~~',.S!?1.... : , - _ -Ckgeni6te-1dfQfSCi0i9t..,...: .......... .... ........:.: o.Ce .~ c~ „ .....~., S~ed9l Seevbe6flif4ite[di10[Bnd~fF (S@96[y) ...~~.,.........,._..~~ ............ ................... ~- . ~ : . :. . . C ' '' _ .. ... .... . .._... .. . erti9edG apieedt~ariE.er~icale( )Q# ae. ~ ......... ..........._-~..... Newde~sey8la~aP~e-rt9te~ndFAfn Feea .. ,.: g ... .. .. (ix~ea~preeedpr~apsaianR+am6s~rya~s) .... _... .. .......... ........ 1ElrouarNal~du~u~enaFM~tmaf-a4uia~ht~p~uabeie Nnt~repape~ ._... .W :. . at~s~lt-M~ta~il~Mn-.l~u+aa~h~ip~o lpra~elmi€ip. YQBdR7~PtYlfl~lMa~i~l~lMllp{~M . ...._ ..._.._... .. ..._...... ~~1.~ ~ir.~, ~t~_/~ .......-`' t:.. fi~c-7 ..... ~4E~IeCll~.f~lCf~d~pnOtiRF~ ~ flM~R bt/~_*iA19 dTCfalf, N63M~6J~7~4 wh~tbelaw. ~- ... ..... .......... ... ......... Otlrerp~pwraib~n bf~e biody - (9n~RiNies lbi7erlfN a b. ............. ............. ~r E3CIBf f"~.°`^rlf .. ...........«........_..... ..«......................_ t~ler(st,6cry}a ............. Q. ...._....._ ................._ b, .......... • ..................... b. ......._........._........ - ~ s ~~- ~rJ~:... .... .. .... ~ ~T....rr~f~-- .._~...~ / ~j ` ~ TC)TALOF~~(7iAR(i~8pa'apr~,da+wwl' ..~~'...._G ..~ . C[ fl7~1 ~ ffi $ ' r . ... , 81C fi 1PP AND R .ATSf~FAC[Lti )$.S t~safFec~IfesentlS~/ftgr DEP~QB/I' . .» . . ~ :: 4 ~ Vle~fian: tst Dpy S ~; _„, ......... ..._. ... ..... .~...... .... . . ........,....._. ~~Y ~' ` ._ ... .. .' BALAA-CEOFF[/11E8ALE~i~: ........ ~ ...;._... !..:::..... ...... d Furte[al......_... __._...~ .._ ........:........~_.... ~ .oo ......_._.~n...~r~~..._....„ AA~rno-istS+a~c-~e...._......._._..._._._;..._...._ ..................._ ._ F~iN!'L,AII; oe~neieeY~ bls~e ~ ne4~d'the purchass (/1#9d6yr~menttindS~a~ fi7r: ~ ~ Q~~~etNd 1i51lttaboY iapli~ i s des~ibed betat4. _: f~eeide3ervfee .. . . t L1.EYenrelorYtac~asaor~rierr#1~8urrors~dlheremafis; ._..... . .._.._. ....._........_ ......._ :_ t 1 2 Your cerielery requl~eei sn ate~erburiel oudeiner' or taw ~ona~t~~ a ianaris b pl~oe aF ~nr t l ~. omet: F+urA~tSewiae4~PpwNees»..._......._ ..:..........._...__..~ :.......__...»_~~........_! ,: CJ" f.`€ 7~~L.~l~ ?BlerShAfandA~6edFaC/kleBTt~TAL:_..,. .......... . ~...,..,~..?,1 ..°..°....... -~~'+P~FM~ Uia a6ors d Ftw~e~l Goods and Servfeea Selected: _ . PHIIf I168nIB Gf L.IctinaE`e: ~ :%/ft f~i; ' ~ . ~ __ (I. TRH\SPORT~TL01~ ' - - - - .. S ._ .- ` AtJ. LFG No.i P _ _ ,. -~~, ~ y~+~.~ ~ _; ~..v _ . < ~~ ;•.~+4"~LMC~ :. _ .~., ~~;u.._ . -..~c.~ .~t ~,~~'~ .~~<,.''f- .vT -.. ,~ ~i - _~~y_ ~ r...e ~-3e~? . "t, ~'f x , _ REV-1511 EX+ (10-06) SCFIEDI~LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,je ~ a '~Q ~ e~ S p~,'f' -~f eot cfOW -'- q ~ 3 a. ~' 1. ~'un~ral ~tnn~~ ~.(l t ri ~ + ~ p r- -~ ~ ~1 n n~ it B. 1 State Zip 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Zip X96 . ~-° /DVS ~' ~~~ ~ TOTAL (Also enter on line 9, Recapitulation) I $ ,%Q ,~Q Z, /D (If more space is needed, insert additional sheets of the same size) REV-1572 EX+ (12-03) corvtrrtoNwEALn~ of i~ENNSVwANw INHERffANCE TAX RETURN RESIDENT DECEDENT SCEIEOI~LE 1 DEBTS OF DECEDENT, MORTGAGE LIABILRIES, & LIENS ESTATE OF f FILE NUMBER STe ~ ~,e >r ~ • ~-~ a d ~c a~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of ~~ in~i~~a~~.. ~~~.a...~...sa ...~:....~ _..____-- tir more space ~5 neeaed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCNEDVLE J COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER S~ e 0. a 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 Sec. 9116 (a) (1.2)J 1. S~-ep~en ~~aVk~- Soh I w . B ~oad.Wa y Tt m ~,o~p ~, ~~ c~2q Na n c~/ S~-a ~ ~-e r ~? I S morn e l-~wy ~m~sper~', NSo Fro36 ~ a u g l-t-~-e r' ~ 3 170 ~o ~ s (-~-o b r) ' D a u~h~'e r ~3 k ~ I 1 ~.-~ v ~e ~ ~r-~ LS~~. ~ ~ F~ 0 013 Y ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 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)