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Home My WebLink About01-29-1015056051047 REV-1500 EX (os-05) OFFICIAL USE ONLY PA Depaltrnent of Revenue Bureau of Individual Taxes County Code Yeaz File Number PO BOX 280601 INHERITANCE TAX RETURN n I ~ ,\ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~(, U ENTER DECEDENT INFORMATION BELOW -~ Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix Decedent's First Name MI k t~~ ~~ R ~ r2 ~~- ~ €~ C (If Appticable) 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 (~ 1. Original Retum O 2. Supplemental Retum 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 Retum 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 Wilq (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 T0: Name Daytime Telephone Number ~, ~o R G C ~-~- S MA- L L ~ r ~ ¢~~ ~ o C Q .~ Firm Name (If Applicable) r--- REGISTER O~VI~.LS USE O~ i 1-n I i I- ~ ~"_" First line of address . ~-~ , ~ g 3 ~ ~ ~~ ~ Y ~~ t r~ Second line of address ~ ' ~'~~ .-:~i -, ~ --i w City or Post Office State ZIP Code DATE FILED ~-n ~,:~ -,-~ , ~'i ~'_; r _> _:~ ': ~ ~ / Correspondent's a-mail address: d`e0~ S YKA ~ ( ~VQ~y I ~-DYI . A ., Under penalties of peryury, I deGare that 1 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 infomiatfon of which preparer has any knowledge. FUK FILING RETURN AUUKt0.7S %~I I~" "V/ ~" // F3 7 V ~n .// r4- ~ o ~i SIGNATURE OF PREPARE OTHER THAN REPRESENTATIVE DATE AUUKtSS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J 15056052048 REV-1500 EX Decedent's Name: ~/I'/'IC K~f~~.- Decedent's Social Security Number ~ ~ ~ Z Z_ ~_~~ ~- RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. 0 • 2. Stocks and Bonds (Schedule B) ..................................... .. 2. (a 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. O 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ...... .. 5. D • 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ~ d ~4/ ~' S , S .~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. p • 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ~ ~ C! ~ ~ • ~" S" 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. Z Z- 8' Cf • S-U 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. ( ~ 2 ( . O O 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 3 ~ ~ p ~ S 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 7 D 7 S . O }~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ! 0 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 le at lineal rate X .0 ~ ~ ~ ~ 5 p ~ 16 3 ~ 8 3 c 0 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. 3 ~ ~' • 3 (~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L, 15056052048 15056052048 REV-1500 EX Page 3 Flle Number Decedent's Complete Address: DECEDEI~S NAME ~~t' ~~ - ~~ ----- - STREETADDRESS ---- -_--______. CITY ____._ ~~/ STATE -T-ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit __ _ _ B. Prior Payments C. Discount -- -- -- 3. Interest/Penalty if applicable D. Interest _ E. Penalty -- - Total IntensUPenatty (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. c1) 3j~'.3~ Total Credits (A + B + C) (2) (3) D O (4) (5) ~~ ~ • 3 & (5A) p B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3 j 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 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 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. REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCl~IED1~LE F JOINTLY-OWNED PROPERTY ESTATE,, OF FILE NUNf~ER Kan asset was made joint wkhin one year of the decedents date oT death, k must be reported on Schedule 6. SURVMNG JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ~co~r ~- cjrnQl/ ~3? /~~r~ ~ .ClGiu~ 6~~ ~ soN ~ ~~- ^~a~ l7a tl B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCULL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER .ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~. a / ~~.e.-ee ~~ ~~~ f~aa~ (~n ~~1 Zo97~. Io ..Sb /o ~/fS~.S~' ~ e~c~f-~ G`~.~ ~ /7 2 U ~..3 TOTAL (Also enter on line 6, Recapitulation) I i ~ ~ ~ ~~ • f'~ (If more space is needed, insert additional sheets of the same sae) REV-1511 EX+ (10.06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEDIILE H FUNERAL EXPENSES 8~ ADMiNiSTRATiVE COSTS ESTATE 0 FlLE NUMBER Debts d decedent must be reported on Schedub L A. FUNERAL EXPENSES: ,. C~ ~rr1•vS~t~ ~~ l ~{~~ B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Sheet Address City Year(s) Commission Paid: State Zp 2. Attorney Fees 3. FamAy t;xemption: (If decedent's address is rxtt the same as daimaM's, attach explanation) Claimant Sheet Address Crty State Zrp Relationshgr of Gaimant to Decedent 4• probate Fees 5. Accountant's Fees 6. Tax Rettrm Preparer's Fees 7. ~2~~ ~~ TOTAL (Also en#er on line 9, Recapihrlation) I S ~~ f , (B more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT Of REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8e LIENS RESIDENT DECEDENT ESTATE ~r~C ~ ~ ~~~ FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, indudiny unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. ~~~p FIR57-C1A55 ~~ ~•.~~ _ ,4` _ ^, q + s - - _. _ USA FIRST-CLASS FOREVFA 1 ''" I ' ~- .~ ~ _ . _ , , ZQiO JAi~! 29 p~ !2~ 5 o~~~~i~.,~~ ~~ou,~~ ,, , > > curer ~I, ,,_ , Pa.. ,~. O O ~ f\ ~~~ ~~~ t~ ~ V Nr M 0 ~ ~ ~ may,.. V 1 t ~`~ I :~--- ~~- ~q, t ~~ } 'I" ~ T j /,