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Home My WebLink About01-06-1015056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Countv Code Year File Number Bureau of Individual Taxes Po Box 280801 INHERITANCE TAX RETURN ,1 ~ /.~~ F~ ~ n cL V v `-~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Seciirity_ Number Date of Death Date of Birth ~~'~ 3o al?~( o B } lo~.boy n~l ~~~35 DF<<~~ients Lrtit Name ~uf(i> D :~-edents First N,1~~~e MI ~ ~) ~- ~- ~ ~ ~ e (If Applicable) Enter Surviving Spouse's Information Below Spouses L~3sr Name Suffix Spouse's First Name MI SK ~u~~~~s S< < ial Se< <mt/ Number ° ~ 3 ~ ~ ~ S ~' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW i 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 Co ise (date of O 5. Federal Estate Tax Return Required death after 1212,-82' O 6. Decedent Died Testate O (Attach Copy of Will) 7. Decedent Mai ained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach CopyTrust) O 9. Litigation Proceeds Received O 10. Spousal Poverty`Creditte of Beath O 11. Election to tax under Sec. 9113(A) bet`Neen 12-31-91.and 1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ,A~~ I ~ .~~ r ~ ~ 1 I~ ~~~ ~/3~ Firm Name (If Applicable) First line of address Second line of address City or Post Office i- -z ~n o ~ n e Correspondent's a-mail address State ZIP Code REGISTER OF WILLS U 5670 NLY , , r; ~. am ~ C ... -~ ~' ~?. ' r_ r't ~ C7 ~ ~- ~m I _. ,;: ~ .1 `-- ~A ILED '~ i " v~ ~ t.;- J 7 ~ y-3 w -:;J ,.t _. ~ _.~ ~) ._% __.> ;~~ ~~ J _~ L-') T~ 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. SIGNATURE OF Pk{tSON RESPO~ ; (LING ~ TUf~N ~ %~~D -x'1`1 n itl/u~Q~,~.. ADDRESS - 1 ' ~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS s ~~ P PLEASE FORM ONLY Side 1 L 15056051047 15056051047 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) .......................................... ... 1. ~ n • ~f (~ 2. Stocks and Bonds (Schedule B) .................................... ... 2. 0 ti • ~ ~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. ~ ~ . ~ Q 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. ~l b [) ~ 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... ... 5. L~ ~ • p fl 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. ~ ~ fl d 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property O S S h d l G t Billi R t d ~ ( c e u e ) epara ng e eques e ..... ... 7. O 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ p . (~ ~ 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. I ,~I~ O , O 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. ~~ ~ • 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. ~\ 4 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. '`; ~ ~ O Q 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which l i ~ an e ect on to tax has not been made (Schedule J) ..................... ... 13. ~ ~ Q 14. Net Value Subject to Tax (Line 12 minus Line 13) :.................... ... 14. ~~ 'Q , `~ D 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. V . Q 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND Of AN OVERPAYMENT O Side 2 L 15056D52048 15056052048 REV-1500 EX Page 3 Decedent's Complete Address: File Number STREET ADDRESS CITY... _. - - _ __ STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit -- -- _ _ __ B. Prior Payments C. Discount Total Credits (A + B + C ) 3. Interest/Penalty if applicable D. Interest E. Penalty (1) (2) -_ - Total InteresUPenalty (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. (56) 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 trans#er 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 "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 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 (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)]. 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.