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HomeMy WebLinkAbout02-01-10 15056041046 REV-1500 ~ (05-04) OFFICIAL USE ONLY PA Deparbnent of Revenue Bureau of Individual Taxes ~~ Code Year File Num ber ~ p INHERITANCE TAX RETURN ~ ~ q~ ~ t ~ ~ 7 Z Hm sburg, A 1~12e-osol RESIDENT DECEDENT , i, ! I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ,..: Decedents Last Name Suffix Decedent's First Name MI (If Applicable) Entar Surviving Spouse's Infon~natlon Below ~ ~ ~ y.~ ~,~ ~~ you S se's Last Name Suffix Spouse s First Name MI Spouse's Soaal Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Retum O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Retum O 3. Remainder Retum (date of death prior to 12-13-82) O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 7. Decedent Maintained a Living Trust ~? 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 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 Firm Name (If Applicable) ° , -~:~ REGISTE ILLS US~ANLY"`~;: :F" ~'•~ ..,~. - -~ First line of address t / r? +p '~ f ~ L . C ~ nl V r C W ~ Q. Second line of address City or Post Office ~'~ E'tT t'i.. '...-~ ~ ~? ' t t ~~. , ~ ~i'-~ ~ F~..-.. Q r,.n #,.,,,,, ,• ~ ~ GATE FILED © _:rR State ZIP Code ~'~ ~~o~~G~~~ Correspondents e-mail address: Under penalties of perjury, I declare that I have examined this return, inGudmg accompanying sd~edtdes and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of pnjparer other than the personal representative is based on aN inforrnatieon ct which prepares has ant knowledge. SIGNATU PE N RESPONSIS FOR FILING RETURN DATE ADDRE SIGNATURE OF P EPARER OTHER THAN REPRESENTATNE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J ~: ,~ J 1505604204? REV 1500 EX /~ Dec~denYsSoaa1 Security Number Decedents Name: 1~1.,,1e~ ,~ ~ S L. ~~ S ~ ~~ _`t ` ~ ~ , ~ . ~.~ . ~_ RECAPITULATION ~ 1. Real estate (Schedule A) ............................................ . 1. g. 2. Stocks and Bonds (Schedule B) ...................................... . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ,, " .. .. .: - ,.. 4. Mortgages S Notes Receivable (Schedule D) ............................ 4. ~. 5. Cash, Bank De posits >~ Miscellaneous Personal Property (Schedule E) ........ 5.: ..11rr 'S r•~^ ' 'ii."~ - ~ L ~b A ,~ ~ ~ ,~ 6. Jointly Owned Property (Schedule F) C Separate` BiNing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property ;~r (Schedule G) C Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. ~" ~: _~ `~, ~ ~+ , 9. Funeral Expenses & Administrative Costs (Schedule H).......... ......... 9. ~~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. ~ ~ 11. Total Deductions (total Lines 9 $ 10) .................................. 11 . . ~ rH 12: Net Value of Estate:(Line 8 minus Line 11) .............................. 12. ~ ~ ~~ d~ ~~~t, 13. Charitable and Governmental Bequesfis/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. ~ F~ ~~ ~ _ _. 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 . ~(s~ ~ ~ d 17 ~ . ~ [j 18. Amount of Line 14 taxable at collateral rate X .15 • 18. 19. TAX DUE .................................................. 19 ~ "~ ~"G ~ ....... . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF"AN OVERPAYMENT O Side 2 15056042047 15056042047 REV 1500 EX Page 3 Decedent's Complete Address: Fits Number ~ooQ.. ~l~~i DECEDENTS NAME STREET ADDRESS OA° I ~Q~. ,v ^r1~ 3~~ ~~~ ~©a o 1~ , CITY STATE ZIP Tax Payments -and Credits: 1. Tax Due (Page 2 Line 19) (1) ~~~ ob 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) {2) ---~"" 3. InterestlPenalty if applicable D. Interest E. Penalty ---- Total Interest/Penalty (D + E) (3) ~~"" 4. If Line 2 is greater than Line 1 + Line 3, enter the diffeerenoe. 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) cj~ , © a A. Enter the interest on the tax due. (5A) °'~ B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (5B)~f ~ , p y Make Check Payable to: REG/STER OF W/1LS, AGFNT 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 ~ income of the property transferred :.......................................................................................... ^ [~t , b. retain the r~ht to designate who shall use the properly transferred or its income : ............................................ ^ [~. c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. ff death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate oonsideration? .............................................................................................................. ^ 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 Individua! Retirement Account, annuity, or other non-probate property which contains a beneficiary des nation? ........................................................................................................................ ^ [~- 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 survivirxJ 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 spcwse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemat 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 tt>e only benefiaary. 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 stiepparent of the gild 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 ore-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)j. Asibling isdefined, under Section 9102, as an individual who has at least one parent in comrrron with the decedent, whether by blood or adoption. i1PF190! D(~ (1~) SCHEDULE E ~„~q,,N,~~TM ~ .,,,,,~ CASH, BANK DEPOSITS, & MISC. 1NH°~""`~ T""'~`~'' PERSONAL PROPERTY ESTATE OF FILE NUMBER ~~ ~ . A ~~ ~- o r ~ v Irx*ide the proceeds d lisgason arKl the dale the proceeds were received bY>he es~1e. AN P~P~Y Ip~h--owned with the right of sumriMOrshlp naat b~ dt~ad on 13dNduie F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. ~+=.t ~ r~ ~ ,.,,~ R Cc Lod ~ ~~~ L t~n~` o ~ TOTAL (Also enter on line 5. Rer,~itulaiion) I s ~~ ~O (If Hare space is needed, insert ad~tional sheets of the same size)