HomeMy WebLinkAbout11-20-09~ REV-1500 EX (06-05)
PA Deparhnent of Revenue
Bureau of Individual Tazes
PO BOX 230601
__. Hamsburg, PA 17126-0601
15056051047
-OFFICIAL USE ONLY
Cou aria Year Fle Number
INHERITANCE TAX RETURN [ ~p~
RESIDENT DECEDENT fast' i ll!
(N Applicable) Enter Surviving Spouse's IMormation Below
Spouse's Last Name
Spouse's Social Security Number
Date of Birth
~l ~~~
Decedent's First Name~~~j','/jl~~' T MI
Suffiz Spouse's First Name MI
~~~
~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~, 1. Original Retum Q 2. Supplemental Retum
O 4. Limited Estate
~ 6. Decedent Died Testefe
(Attach Copy of Will)
O 9. Litiga0on Proceeds Received
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
O 10. Spousal Poverty Credit (date of death
between 12-31-91 end 1-1-95)
~O 3. Remainder Retum (date of death
prior to 12-13-82)
~O 5. Federel.Estate Tax Return Required
3. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - TNIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
UD I ?~ -1 /
Finn Name (If Applicable) -.; •;~
RE018TE~. ILLS US ONLY r : !..~
O
~C "- ~~
First line of address ~~ ~ m IV ~ r r
77
A ... ....-. . ... -_ cri ~ O _ ~.:~
Correspondent's a-mail address:
Under penalties of perjury, I dedere Thal I have examined this return, indutling accompanying schedules and slatemenis, and to the best of my knowledge antl belief,
it N true, correct antl complete. Dedaralion of preparer other man the pereonal representative is based on formeuon of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETUR ~ DATE9
ADDRESS ~ n ~ l J // /~ ~/
OF PREPARER OTHER THAN
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051047 15056051047
15056052048
REV-1500 EX
Decedent's Social Secudty Number
Decedent's Neme: r ~ ~ x.. -~ ~ ~ ~ ~ ~.
-`c .'.. t«.u.~X uW'e.
1. Real estate (Schedule A).... .. ... ...... .. .. ... 1 + '.
~ h
2. Stocks and Bonds (Schedule 8) ... ..... 2 T e ~ ;'
3. Closely Held Coryoration, Partnership or Sole-Proprietorship (Schedule C) .... 3 - - n '
,Y~' :~ ~'~*~'~3"~ *~
4. Mortgages 8 Notes Receivable (Schedule D) ........ ......... ......... 4 ;i;
5.~ Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5 ~ ~ ~.jvZ, '7 y V ~
±M ~'
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... 6 ,, ~
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property -,~&t~~ raw rF,y.`„~~„~yxx,~.+'+ ~~ ^~~~'£
(Schedule G) O Separate Billing Requested........ 7 ` x = xx t ? '~
~ t y~a
. [c...,~w+"#'Y$6x 3dvv.x +~~t~ `~,r,T,x "'i%a~
8. Total Gross Assets (total Lines 1-7) ..... .......... ........ ......... 8. 4 ;; ~'t oC. ~ a '1
9. Funeral Expenses 8 Administrative Costs (Schedule H) .... .. g , t '`" x ("]~. ,"
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ... ... .. .. 10 r ~aO ~~3 e
11. Total Deductions (total Lines 9 8 10)...... ... .. .. .. 11 Q ~ ~ +~41, " ~J
12. Net Value of Estate (Line 8 minus Line 11) .. .. ... 12. ' i ~ +_~ ~
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~:'~¢$L~~c '~""~!~' ~ ~~`"4r~F ~.`~.~.~ x;,:+ ?
an election to tax has not been made (Schedule J) ... ........... ....... 13 3i ~. ~, ;
14. Net Yalue 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 ~ ~~~ y._=~
18. Amount of Line 14 taxable *'" .t+ - + „'i~o s2` *~ ~ ~ F
at lineal rate X .0 _ '" 16.
17. Amount of Line 14 taxable ~ ~f" tw1:':'r".,~ + r' ~"~ "'~ ~~_ ="f~^~-t~~*t
at sibling rate X .12 1 _ ~ 1 T
18. Amount of Llne 14 taxable 'r• # ~- °"' ° "' e°~ "$ ~ ~°L r "'
at collateral rate X 15 ~ ,~ 18
u _ ~ h au..,k,.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Side 2
15056052048 15056D52D48 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DE EDENT'S NAME
STREET ADDRESS ~ - ~ ~ y~ ---- _ -- --------
_. ~~Yl~/, !x(40 ~wv~ L _ i 1 f.~,
clTr ~vU -~ -- - --~
STATE /1 !ZIP
~J /?O1.3
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
Total Credits (A + B + 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 fo 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 + SA. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(56) D
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 transferced :................................................................................... ....... ^ Q/
b. retain the dght to designate who shall use the property transferced or its income :...................................... ...... ^ [~}-
c. retain a reversionary interest; or .................................................................................................................... ...... ^
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^
2. If death occurced after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................................................................................................ ...... ^ Q'
3. Did decedent own an "intrust 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 benefciary 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 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 exemot 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 (O) 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.
REy.1518 E%.IIA11
SCHEDULE E
CAMMDNVJEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IR RESDENTDECEDENTRR PERSONAL PROPERTY
ESTATE OF ~ r FILE NUMBER
InGude the proceeds of iNgation Lnd the date the proceeds were received by tllYesta~. All property Jolrldyowned with the dgM of sunrhrorship must be disclosed on Sehetluk F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
,. ~ Wt ~-- % 1~ arc 'I~~.Cezr-.-,~`- ~ `~ ~! S3 a d
TOTAL (Also enter on line 5, Recapitulation) I S ~' a ~~
(If more space is needed, insert additional sheets of the same size) '
. REV-1511 EX+(12-9e)
scNEOU~E x
' COMMONWEALTH Of PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Deb of decedent moat be reported on Sehetlule I.
A.
1
S.
1.
2.
3.
4.
5.
6.
~.
FUNERAL EXPENSES:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Secudty Number(suEplN Number of rsonal Representatives
Street Address _ _ ~ ~ / 9~ ~ j ~ ~~ ~ W.~
City N~il.l.y v 1 11~. '~Ct, I O Stat~~Zip ~_
Year(s) CommissioCCn Paid: ~ q1 _n q
Attorney Fees S aeC~.~ y ~ lD IA.t11 a- ~ ~r "WC.¢ p,~
Family Exemption: (It decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Retum Preparer's Fees
'~/
/~~'.
~~
TOTAL (Also enter on line 9, Recapitulation) I $ 9 ,
(It more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03j
COMMONWEALTH OE PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, Sr LIENS
RESIDENT DECEDENT
ESTATE OF
~.. •~•-~- .,r...... ~~ ~~~=~=u. ~~~o~~~ wmuvuni aneeu of me acme srzel