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J 15056041046
REV-1500 EX (05-04)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes
Dept.28o601 County Code Year File Number
INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ,~ ~ ~~ ~ I- ~ ~' `~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
~~~~i ~~~/l~ 1 ~ ~~' ~~ .~N
~ .~ t~ ~? 3
Decedent's Last Name Suffix Decedent's First Name MI
,~
(If Applicable) 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
!p 1. Original Return O 2. Supplemental Return p 3. Remainder Return (date of death
O 4. Limited Estate prior to 12-13-82)
O 4a. Future Interest Compromise (date of p 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate
(Attach Copy of Will) O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(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 TO:
Name
Daytime Telephone Number
_y
~
Firm Name (If Applicable) ~ ~
-~
REGIST~iRWILLS US760NLY ,
First line of address C..~' '---- r'n - i
t; 7 = 7 L"~ ~ ~
r_. i .'
i .r
~ti:. ,. ~ _
Second line of address ~.~~~~~ - -' ?
~C) ~
City or Post Office State ZIP Code DATE FILED ~
7
Correspondent's a-mail address:
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 PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS +
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 15056041046 15056041046 J
J
REV-1500 EX
RECAPITULATION
Decedent's SocJial Security N~uJmber f ,,
1. Real estate (Schedule A) . ............................................ 1.
2. Stocks and Bonds (Schedule B) 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ............................. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5.
C /f Cc. fG I i~l ~ ~~-~--~ i~ r
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~
(Schedule G) G Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) .................................... 8. •
9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. f ~ I ~-~ ~ •
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) :~ .~~'!;1. 4 X1.1• • 10. U
11. Total Deductions (total Lines 9 & 10) ................................... 11. •
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. •
13. Charitable and Governmental Bequests/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. '
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15.
(a)(1.2) X .0_
16. Amount of Line 14 taxable 16.
•
at lineal rate X .0 - `
17. Amount of Line 14 taxable
•
17.
at sibling rate X .12
18. Amount of Line 14 taxable ~ 18
at collateral rate X .15
19.
19. TAX DUE ........................................................ .
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
15056042047 15056042047
15056042047
O
J
REV-1 EQO EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
-- _-- -
STREET ADDRESS
-
cITY -- _--
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
- --- - -
iscount
3. Interest/Penalty if applicable
D. Interest
E. Penalty ---- - -
File Number
------- -------
STATE I ZIP -- ---- - _
~~ I ~C1~S
Total Credits (A + B + C) (2)
Total Interest/Penalty (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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
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 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
c. retain a reversionary interest; or .......................................................................................................................... ^ 0
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? .............. ^ 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................................................................................................. . n
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 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 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-1511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCMEDIJLE M
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
~'~ ~~ L ~ rt1 ~ .~ ~;~ ~ r
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A• FUNERAL EXPENSES: ~,~{ I ~ ~ ~ ~ r ~~ ~ , ~ ~ ~~ ~~~~
,. ~l 3
s ~ ~~~ ~ ~ c ~~ i / ~`~ ~ t~; ~=
...r -
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
State Zip __
2• Attorney Fees
3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
City
Year(s) Commission Paid:
Street Address
City State
Relationship of Claimant to Decedent
4• ~ Probate Fees
5• ~ Accountant's Fees
6• ~ Tax Return Preparer's Fees
7
Zip
~:J ~j ~ c~'• S C~
TOTAL (Also enter on line 9, Recapitulation) I $ ~~ /~_.L
(If more space is needed, insert additional sheets of the same size)
~~~~
REV-1508 EX + (1-97)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RESIDENT DECEDENT RN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
y•~~=~~
TOTAL (Also enter on line 5, Recapitulation) I $
(If more space Is needed, insert additional sheets of the same size)
C~R~'IPICATION OP NO'T'TC~ UN~~'R P~. O.C. Rule ~
-- •~~a)
REGISTER. OF WILLS
COtJ~,rTY, PEN~vrSYLVAti'IA
Narne ofDecedent:
Date of Deatll:~ / ~'; n e~
File ivumber:
Date Letters Granted:
To the Register:
I certify that Notice of Estate Administration required by Pa. O.C. Rule ~.6(a) of the O hans' Court
Rules was served on or mailed to the following beneficiaries of the above- a ~
.... c phoned estate on
Name: '' Ad_=•
(Ifmore space is needed, attach separate sheet,)
Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) exce t:
P
Signature ojPerson Filing this Fonn
Capacity: Q Personal Representative ^ Counsel
Name ojPerson Frlrng lhrs Form
/~-~ / J' 1 ~ / y
Adds ess ~ ..~ ~• ~ f;- , • .. - ~-- I y C'L ~1
~~ J~ l fit' ~°'
Tzlephone
Fonn RW-08 rev. 10.13.06
Pa. O.C'. Rule 6.12 ST ~TUS REPOi~T
_.____
-- -- -_.
____ - _--
REGISTER OF ti~ILLS OF COUiv'TY, PE~`NSYLV~~TI.A-----
Name of Decedent: ~~t.~/;-~f j 1y~ ~^~~~,~,~
Date of Death: ~' ~/~ ~~ ~~ ~ _ File Number:
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
[~ Yes ~ No
1. Stag whether administration of the estate is complete:......... ~.......... .
2. If the answeris Iv'o, state when the personal representative
reasonably believes that the adininistrationwdl be complete:
j l~l P~ ~h G u AI i~ S
3. If the answer to No. 1 is YES, state the following;
a. Did the personal representative file a fnal account with the Court? ....... ,Yes ~ No
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account
informally to the parties in interest? _ ........... ................. QZ'es ONo
d. Copies of receipts, releases, joinders and approvals of fol-mal or informal accounts maybe
filed with the Clerlt of the Orphans' Court and maybe attached to this report.
Dnre ~=~, ~~ C~ ~j~
Sig~ialure of Person Filing this Form
Capacity: ]Personal Representative Q Counsel
Sat*~
Nnuie oJPerson F/ilinglliis Form/
Address
Telephone