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Home My WebLink About10-15-09J 15056041D46 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 Hamsburg, PA 17128-0801 RESIDENT DECEDENT 2 I- ~ ~ ~ ~ ( ~ ~ ~__ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~~ ~ i ~_~~~~.°.~~_ arm' ?` 1 as ° ~`.~ b d g o ~ © so t ~ r Decedent's Last Name Suffix Decedents First Name MI F. ~ - A' R S?T? A?~: ~~ G F o R G ~ G 4 (If Applicable) Enter Surviving Spouse's tnfonnation Below Spouse's Last Name Suffix Spouse's First Name MI ~. Spouse's Social Security Number x THIS RETURN MUST BE FILE D IN DUPLICATE VNITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 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) 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 $ch. 0) CORRESPONDENT - THtS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Teleplhone Number Sr~v~Enl R GAR S-T~~ Firm Name I If Applicable) REGISTER OF WILLS USE ONLY ~ ~ N ~ r~ First line of address ~/ .2~0~ µv~sSF~R ~~eR SRI -r,? v~ ,`~ Q --i t w J ~'~ Second line of address -= ~z7 .; ~ ~ r '' : "r'2 _:~ ,: ~~C ~`~~ C ' ,~ _ ~ y City or Post Offce State ILED ZIP Code ~ „_ 5:[ ;° Correspondent's a-mail address: ~"I G v ~ a r s '~' a e;~ ~ o`p r~ ~- ~~ .~ r k yr ~ f Un er 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 whichipreparer has any knowledge. SIGNATitiR>E OF PERSON 13ESPON L FOR FILING RETURN DATE ADDRESS Ltln~rFR~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J RE`J-1505 EY,+ (G-92) r ~ol/~I~nonwdEr.~r~ of REIViJSVLVAIJ~A IIJHEP,ITANCE TkX RETUP,N RESIDENT OECF_DEIJT ~~~~CC ~ICL= C ~CI~~Qf\f~f ~~~~~~:~` ESTATE OF FILE NUf~i6ER Include the proceeds of Gligation and lhe~data the proceeds were received by the. estate. Alf property jointly-owned with right of survivorship must be disclosed on Schedule F. pr more space Is neetled, insert additional sheets of the same size) REV-i511 E::+j12-89) r~s ,~~~ ~~C~CzCCC~~~ Cz .. ~...`~~l_' COIF/I~gOI~iVVEALTH Or PENNSYLVANIA ~~~tiC~~~ ~~<C~~~w~~~' INHERITANCE TAX RETURN ~(~,r`/~~~~`~~~~5~~ ~~/~ ~~~;~,~°~~ RESIDENT DECEDEIJT E~TAT E OF FILE I~~Uft4EER C~EORG~ G ~~4R:Si~a Debts of decedent must be reported on Schedule I. ITEM fV{aA46€R ~• DESCRIPTION - I Ah40UNT A. FUNERAL EXPENSES: 1. NEB ~~ FuNERA L ~lo~'V1 F , NA~RrSg~,2~,, d~i4 ~~S•`~~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption; (If.,decadent's address is,not the.same as claimants, aitach.explar~tion)~ - Claimant Street Address City State Zip _ Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. i ~ 4 ~ ~u tcr~ L/}Sp~Q~ l'A- t t rL~ TR~n! SF1~~ ~~~~~ssa-Ry ~~R c«q..~ ~~r-~B~£ o ~! l4 T ~ o ,v/ ~! a . S o T~FA~.(Afsa~. eni!ec~n: f'rnn ~; ER~pit~let~a~*~: ~ ~±-~. ' ~ _ ~j 7 , (If more space Is needed, insert additional sheets of the same size)