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Home My WebLink About03-09-10 REV-1500 Ex c~-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 HarrisbunA. PA 17128.0801 15D56051047 OFFICIAL USE ONLY INHERITANCE TAX RETURN ~~ II~ Year FNe Number~~l1 RESIDENT DECEDENT ~ 1 Q Q d` ~ G ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth I~2 ~6 R~~ t oaal aooq o6oa 1~4a8 Decedent's Last Name Suffix Decedent's First Name l~h ~ S+ I ~r ~a r r• (If Applicable) Errtar Survivlnp Spouse's Information Btrlow Spouse's Last Name Suffix Spouse's First Name (~h ~ 5~ I ~er 4 e~-~y I~ Spouse's Social Security Number THI8 RETURN MUST BE FLED IN DUPLICATE WITH THE ~8 ~ L~ `~ (~ ~ S REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW MI MI t~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-1382) O 4. Limited Estate O 4a. Futuro 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 Llving Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wily (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credk (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 NurrlGer 5d10.fOn ~e-~ ~~ Firm Name (If Applicable) First line of address 5'~I(o W Penn ~~ Second line of address Cily or Post Office Ste Carl i5 fie. ~' to ZIP Code REGISTER OF WILLS USE ONLY N O ~~ a ,--~ a ( ~r ~ ~7 ` =~ c;r~ n DATE ~~'7 -~ ~ i c~ ~, ~'.„ f ~ ul (. ~T.. ~ C ~ ~,.; ~? ~.... ~;s j f'.~. cn~ 7 Correspondent's e-mail address: S S ~ ~ ~ F ®~ Under penalties of perjury, I declare that 1 have examined this return, including acx:omparrying schedules and statements, and to the beet of my! knowledge and belief, it is true, correct end complete. Declaretlon of proparer other than the personal repreeemative Is based on all Infonnetlon of which preperer hPs any knowledge. ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEABE USE ORIGINAL PORM ONLY 31de 1 L 15056051047 15056051047 ~" iti1 15D56052048 REV 1500 EX Decedent's Soda) Security Number Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) ............................................. 1 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Ck>sely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Sdiedule D) ............................. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 8. Jointly Owned Property (Sdiedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property ~ • • • • 50 o o • 00 I ~ (Schedule G) O Separate Billing Requested........ 7. • 8. Total Gross Asssts (total Lines 1-7) ........................ ............ 8. ~j (`~ ~ Q ~ • ~ ~ 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. ~ f ~ ~ ~ ~ • ~ f 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .... ............ 10. • 11. Total Dsductlons (total Lines 9 8 10) ....................... ............ 11. 1 i-, ~ 1 ~ • ~(y 12. Net Value of Estate (Line 8 minus Line 11) .................. ............ 12. ~ d ~ •3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has rat been made (Schedule J) ............ ............ 13. r 14. Net Value Subject to Tax (Line 12 minus Line 13) ............ ............ 14. 3 ~ ~ a ~ • 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9118 16. Amount of Line 14 taxable ~ at lineal rate X .0 _ ~ . 18. • 17. Amount of Line 14 taxable ~ at sibling rate X .12 + 17. • 18. Amount of Line 14 taxable at collateral rate X .15 • 18. • I 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 1505605204$ G O REV-1500 EX Page 3 Flle Numl»r Decedent's Complete Address: DECEDE S NAME rt'~_ ~- ---- ~ ~, ~--- ~ f-~r. --- - - - --_. _- --- -- --- _ -- srREET DRESs ---_ _- ---- _ 7 CITY I~--~ -- -- ZIP / C Q i Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPaymeMs A. Spousal Poverty Credit - -- -- _. --- -- -_-- B. Prior Payments C. Discount __ ___- - Total credi~ (A + B + c) (2) 3. InteresUPenaltyrf applicable D. Interest _ _ _ E. Penalty ---- -_-_-T_ _ Total InteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, errter 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. Eller the interest on the tax due. (5A) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) 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 a income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its insane : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either paymerrts, benefits a care? ...................................................................... ^ 2. if death occurred after December 12, 1962, did decedent transfer property wiUlin 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 benefiaary designatbn? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A~ PART OF THE RETURN. LI 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. §91111 (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 p2 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 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 decedents lineal benefiaaries 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 decedents siblings is twelve (12) percent (72 P.S. §9116(a)(1 ~3)]. A sibling 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-1511 EX+ (10-09) ~ Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decederd'e detdu must be reported on Schedule i. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: (~ 1. F-W~n~ (3~a~~e~S ~i'Url~ra. ~ l~r'le. ~ ~ ~c~o. ~C~ C -~ ~ rqY,`~ ~e (~Jor ks ~ ~ f 3 , Oa B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) __ __ _ ____- Street Address ___ City - - - - --- -- __- -..- State ---ZIP Year(s) Commission Paid: _ -__ ___ _- 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as dafmant's, attach explanation.) Claimant Street Address _ City __ -- - _ -- _ State _ _ _-ZIP Relationship of Claimant to Decedent _-_ 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) (~ ' ~ ~ ~ -I ~j , If more space is needed, use additional sheets of paper of the same size.