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Home My WebLink About03-31-10 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number REV-1500. EX (DS-D4> PA Department of Revenue Bureau of Individual Taxes Dept. 260601 15056041046 OFFICIAL USE ONLY County Code Year File Number Last Name Suffix Date of Birth d~~ Decedent's First Name MI s ~ M. Suffix Spouse's First Name MI w.~ t PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041046 15056041046 J 15056042047 RECAPITULATION 1. Real estate (Schedule A) ........................................... . . 1. 2. Stocks and Bonds (Schedule B ' ' ' ' ' 2' 3. Closely Held Corporation, Partnership or Sale-Prwprietorship (Schedule C) .... .. 3. 4. Mortgages & Notes Receivable (Schedule D) 4' 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .. - . 5. 6. Jointly Owned Property (Schedule F) G Separate Billing Requested ..... .. 6. ,' 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property C Separate Billing Requested..... ... 7. (Schedule G) 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. 12. .............. Net Value of Estate (Line 8 minus Line 11) ............. ... 12. 13 . Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 1 an election to tax has not been made (Schedule J) .. - . ~ € 14. NeYValue Subject to Tax (Line 12 minus Line 13) .................... 14. i ... . 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 ja~ble 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. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056042047 15056042047 REV-1500 EX Page 3 File Number f1e.....~....u_ n_.Y_~_._ . ~-'- ~~~~~~... v vv~nr~rac AYYIQa~7. _) DECEDENT'S NAME Q~ STREET ADDRESS ~ ~ ~ ~ -- n / ,Q ~J CITY (~,~r ~OD- l NII~~G~ i `GY \ ~4r1I~ ~ /~, // ~ STATE~4 ZIP ~~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments r A. Spousal Poverty Credit B. Prior Payments C. Discount .~ Total Credits (A + B + C) (2) _.,,~_ 3. InteresUPenalty if applicable D. Interest E. Penalty _ h ~ 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. (q) ~~ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ g, u,~ ~ ~ A. Enter the interest on the tax due. (5A) -~/ •~( - B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) (~~,~/ 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. 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. REV-7508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, 8~ M1SC. PERSONAL PROPERTY Include the prgceeds ofJitipaGon,and,the,>iate.the.pruceeds,were received,bythe.estate. All property Jaintlyowned with right of survivgrahip must be disclosed on Schedule F. '," - _. ~~~sDa/f/ (,IIP~'Ky /~c~ou,r-7` !o . ~.T ramie . 8~r~i 9 / o` 74pns~erwr// Ti/ e3T,>`h ck$ .gCer" Bets®yx( ck5• qr~7 sgaete;fK b~. ~t 19//06~'S77 ~•c' ~u~d o~ /ac r/dv'~ ~i er-tG .ry.cwar~e / ~~-~ y/o i! ,rP~~s.`T,~d ,~w7-o ~sTrTE ~/orou,~.7'~ GSI~-Te /FccT SOOe~/~H l~.sk ~r~~ ~~~ICylo7-3 ~ys~;.~, C~.~/~~ ~~l/u/7r~ g.rT ej5 ~ dwey a.,~e %denTo,~ /t7vKS//t / .(. S 5 ~9rf' ~IIe ~CU9e~K4 _ rC6.~LLNre ~'eWawr oK~4 ~ . J I\/~!/orZ,eK /royns J~ur.e Or`ueH /~ckr ~o ~ie~c IFan~TTe HIE . ~ ewe Nto -~uKh;T/.~fe el ~~~w L~J~~/~.s ~,s ,~,~/~ ,~'CebcSec~ ~ZItS~o..c~ ~jsr® c~ece~~p~ l/Os+~ ~fl/~K a~r`°,~~ BOG !S yP!l~c3 ~C/ JK %O pB~7`~t o ~~ /~ ~sr~e ~d ,tam ~~,K,-~- 7o quK1c~~ irO,erE TOTAL (Also enter on line 5. Reranind~fi~~7 c (Ifmgre space is,needed,,inserFadditlortalsheets of thesame size) FILE NUMBER Q~! VALUE AT DATE pq0- F DEATF{ T/•~ 3s9~~j' aep•oo /f/9-BO ~5fs' 3 ~' REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT G.J IAIh OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS .Debts of decedent must be reported on Schedule.L .FILE NUMBER A• FUNERAL EXPENSES: 1. P~~~~`~ B. I ADMINISTRATIVE COSTS: 1 • Personal Representative's Commissicns ..Name ef.Personal Repfesenteti¢e(s) Street Address City Year(s) Commission Paid: 2. 3. 4. 5. 6. 7. State Zip Attorney Fees Family Exemption: (If decedent's address is not the same as GaimanYs, attach explanation) Claimant Street Address City State _ Relationship of Claimant toyDecedent Probate Fees •T ,5?rip ~~~re.~ ~'~rAdrR~~ Accountant's Fees Tax Return Preparer's Fees Zip ,S7 '00 TOTAL (Also enter on line 9 Recapitulation) I $ (If more space is needed, mserl addlbonal sheetsof •the same size)