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HomeMy WebLinkAbout12-10-09J 15056041046 REV-'i 50o EX (05-04} OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ' Dept. 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~_ ' ~ a ~ ~ ~-`~_~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~~. ~:q.~¢~ t ~~ ~ ~:~;~ ~ ~ ~ is i..~~~~~-~ Decedents Last Name Suffix Decedent's First Name MI r r.. (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number +., FILL IN APPROPRIATE OVALS BELOW tl• 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH tHE REGISTER OF WILLS 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) 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. 4) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone'Number Finn Name (IfAp~licablei First line of address 5~ 1,v 1~Gv y~F~ ~r ~/ Second line of address City or Post Office State ZIP Code REGISTER Ofr WILLS USE ONLY ~ ~ ~, rr'I ~.f 7 - 1""D ED ~"~ ~~.Y , C J? X --. P ~}- 17 v ~~ ~~" .- Correspondent's a-mail address: -~ E,~ ~~ -r~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the bestiof my knowle ge and belief, it is tn,e, correct and complete. Declaration of preparer other than the personal representative is based on all information of which prepiarer has any knowledge. SIGt~TURgOF PERSON I~SPpNSIBLE FOR FILING RETURN naTF . '1C' /~, SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 150560.41046 J RECAPITULATION ._ 1. Real estate (Schedule A) ............................................. 1. ;. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or StYfe-f'topietorship (Seh~dule C)'...: 3'. ~. ~ _ _ 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. •. 7. Inter-Vivos Transfers & MiscellaneousNori-Probate Property (Schedule G) C Separate Billing Requested........ 7. ; ,~ 8. Total Gross Assets (total Lines 1-7) ..................... ............. .. 8. - rr i_. ~ : Q # ~ _ - ~, ~~ . ~,. a ~s..~- ~~--,ai w v ~e~- p 4 fJ eb ~ ~ 9. Funeral Expenses & Administrative Costs (Schedule H) ...... ............. .. 9. ; 10 .a =y, ~ /~. `` i Q v 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 9 9 ( ) . ............. .. . , r 11. Total Deductions (total Lines 9 & 10) ...............:.... ............. .. 11. ~~„~ ,~ V ~ ~ # 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. Net Value Subject to Tax (Line 12 minus Line 13) ......... ............. .. 14. ~ V TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ *. . 16. Amount of Line 14 t xable l X 0 ~ t l t O s ~ ' ~ 16 ~i.e;~ }`~ ~ t^~ J Q l 17 ra e . a inea Amount of Line 14 taxable a . , , . ~ ~ V " ~ D `O at sibling rate X .12 ~ 17 18. Amount of Line 14 taxable ~} !" `~~ O 18 /~ '`~ ~ ~ ~" ~ at collateral rate X .15 j . ~ 19. TAX DUE .........................................................19 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~r~.,~"_ O Side 2 L 15056042047 15056042047 Complete Address: Tax Payments and Credits: 1. Tax. Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit __ B. Prior Payments C. Discount c1> a~66 Total Credits (A + B + C) (2) ©~ 3. Interest/Penalty 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 tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. c3) 6~ ~ (4) n. (5) D~~~ (5A) D ~ ~CJ (5B) ~~ Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPiRIATE 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? ................................................................ ...... ^ 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 trust 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? .................................................................................................................. ...... ^ 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 fbr 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 (ax 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 p2 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. REV-1500 EX Page 3 File Number ;,(1 ~~ -' ~ ~ 3