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Home My WebLink About04-29-10 (3) 15056051047 06 05 REV-15 0 0 EX ( - ) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN County Code Year ~ / ~ U File Number O ~ Z p Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~.D~ ~3 a/S~ O/ 3 I 20/0 0~' /2 ~9Z.Z. Decedent's Last Name Suffix Decedent's First Name MI ~PPL~R ,bo/{ i ~ r3 (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 m' 1. Original Return O 2. Supplemental Return 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 Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ® 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 ~~~ti~R~ ~' ~~wR~l ~xE~ ir7~G3 ~~99 Firm Name (If Applicable) `~` First line of address ~z~ ~~e.~AR G,~~E Second line of address City or Post Office State Correspondent's a-mail address: ZIP Code REGISTER @t=1~VH~LS USE (9I~LY _?~~ . ,,~ :. ~: ~. ,;~.. ,. DA E FILED Under enalties of perjury, I at I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, i rue, c rrect and co plete. Decla ation of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT E OFrPER N SIBLE FOR FILING RETURN DAT~ ~ / ~4 ADDRESS ~ ~ ~ D/~~ ~ n~~ ~~AAA Q~ /t ~T !_`/J Rs1~v~PG-. ~i4 ,/726. ~- SIGNATURE OF P T R T R ESENTATIVE DAT ~~ ~ ~ 9 /o ADDRESS a 9 ,N - S /' c a N~ ~ Tr ~//J,~i.S~ u2G , PR ~ pia Z PLEASE USE ORIGINAL F01tM ONLY .: ,~ P ,...::~ ., _~ ~~:, ~ - ~:~ - ._f~t ~~ ~i"T`1 ~ Z ..? ~~ Side 1 15056051047 15056051047 J J 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. 0 • ~ ~ 1. Real estate (Schedule A) . ........................................... . 2. Stocks and Bonds (Schedule B) 2- ~ ' ~ U 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~ •~ U ~ ~ 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. • 5. 6. 7. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... Jointly Owned Property (Schedule F) O Separate Billing Requested ... Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... .... 5. .... 6. .... 7. o~ l ~ ~ ~ T • ! ~`' / ~ ~ • ~ d f d • ~ 8. Total Gross Assets (total Lines 1-7) ................................ .... 8. ~ ~ / ~ ~ • 9. Funeral Expenses & Administrative Costs (Schedule H) ................. .... 9. ~ ~' b ~ . ~ ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 10. • 11. 12. Total Deductions (total Lines 9 & 10) ............................... Net Value of Estate (Line 8 minus Line 11) .......................... .... 11. ... . 12. ~ 7 .s ~° o ~O a ~ b O 7 ~... / 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... ~:~. » 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ s ~ ~ Z TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 _ . 16. • 17. Amount of Line 14 taxable ~' L at sibling rate X .12 4 J Q / ~"' ~ ~ ~ 17. ~ ~/ S~ / d • d 18. Amount of Line 14 taxable at collateral rate X .15 ' 18. 19. TAX DUE ...................................................... ...19. S ! ~~•v ~O 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 J REV-1500 EX Page 3 File Number Decedent's Complete Address: ~0~ ~-~l DECEDENT'S NAME D a ~/ S ~ . ,~pP,~'/~ _ __ STREET ADDRESS _ _ __ __ _- _ _ _ _ CITY. _- _ - _ _ _ _ _ _ _ __ _ ~ STATE _ - _ __ __ ~1.c G ey,4,v~GS/~v ~C ~ ~A zIP ~ ~~ S ~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) ~7 d~ , o (o 2. Credits/Payments A. Spousal Poverty Credit _ ___ B. Prior Payments C. Discount ~ ~~, 2 S _ Total Credits (A + B + C) (2) ~ ?D, 2 ~ 3. Interest/Penalty if applicable D. Interest __ _ -- _ E. Penalty __ - __ _ Total Interest/Penalty (D + E) (3) O, ~ 9 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ / ~ ~_ ~' A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~ / .~ / r ~' 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 :.......................................................................................... ^ ~]C 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? ...................................................................... ^ 0 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 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-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA fNHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDt~LE A REAL ESTATE d OR/S ~, ~-~~o~Jp FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market valu ~~ ~ ~ exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge lof theWelevant facts would be Reaf property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~, ys ~ ~ ~~~ u3~ ~D~ OF DEATH y~-,~~es ~~~ ^ ,,, ti~~s~,~~ ~~s~~ ~s~ ~1'G.4~S TOTAL (Also enter on line 1, Recapitulation) I $ /f/ d /V'/' (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF s~wE~u~E s STOCKS & BANDS ITEM NUMBER 1. .~ ai!i.~ ~_ «PL,,~-,~ FILE NUMBER AU property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION TOTAL (Also enter on line 2, Recapitulation) I $ (If mare space rs needed, insert additronai sheets of the same size) 1162 Z ~' VALUE AT DATE OF DEATH a /L d ivy REV-1507 EX+ (1-97) Y, y ,. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER lf4Z~.~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH d TOTAL (Also enter on line 4, Recapitulation) I $ ,/V~~/~ (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (1.97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE pF d R /S l'. ,C i°P~LF~ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FfLE NUMBER ~n?~d ~~ ic~uae me proceeds df litgation and the date the proceeds were received by the estate, All ro N V ITEM p party Jointly-owned with the right of survivorship must be disclosed on Schedule F. NUMBER DESCRIPTION VALUE AT DATE 1, /V u T///N Qi- d f 1/'~~. !/ ~ ~ T /I~ ~i ~(S'//I/ G- ~p n,~.,E OF DEATH ~v :~ . n, v,~~ ~ti ~ ,yd.~c R,EF'v~v/~ ~ ~ ~c-~ v ~~ ~a r- r,E~ ~ 3 i l d ~ ~D ~`. `~~ TOTAL (Also enter on line 5, Recapitulation} I $ ~ ~~! ~ ~/(, (If more space ~s needed, insert addlt)onal sheets of the same s(ze) REV-1509 EX + (t-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY Qa,Q/ f ~~ ~-~o~,~~ FILE NUMBER ~®z~~ ff an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS A. /~i cyA,2a ~, ,~ awA N y~ ` ~~~,~~ L,4/~r,E ~` Z ~ B ~i~~ L~N~ ~~i/J/t'l~3~~S ~ vtC ~'/J / 72 ~ B. I C JOINTLY-OWNED PROPERTY: LETTER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT RELATIONSHIP TO DECEDENT 8~or~~-~ DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD S DATE OF DEATH deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST ANC G',~.ccl~~~~- Ac<~~~ti; ~f~ q~3_ pv 5~~~/ ~}~ 923, 9~ Ti~'..~n, 5 F~~( ~Nl ~ r~ 4 i ~ 3 0 u c~ ~ ~~ ~ ,S' ~'/ ~ a b 6 3~ S- TOTAL (Also enter on line 6, Recapitulation) 1 ~ '~~ ~ z ,~ 9 D (If more space Is needed, Insert addltlonal sheets of the same size) ~~ ~ SCHEDULE G COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS & INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF A U t3 ,l° / .~ ,~ _ ~'~o~o,~~ FILE NUMBER OO •Z 2 S' This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-9500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. % OF JMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH DEC,D'S ~ VALUE OF ASSET INTERES' ~1/'®MC TOTAL (Also enter on line 7, Recapitulation} (If more space is needed, insert additional sheets of the same size) EXCLUSION ' TAXABLE VALUE ~'t/ d:N~ REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE f7t= SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ITEM NUMBER A. 1. ~D Q ~ / ~ & , ~" P~ [~ ~ FILE NUMBER ~~ 22 ~ Debts of decedent must be reported on Schedule I. --` FUNERAL EXPENSES: DESCRIPTION v ~~N r. ~.~-u .~r,~,~ ,=~,,,~~~. ,yew ~.uc /3~ Y ~, ~~~ Si , _ i B. ~ ADMINISTRATIVE COSTS: ~ • Personal Representative's Commissions Name 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 claimant's, attach explanation) Claimant Street Address City State Zip -___ -.__-_ _ Relationship of Claimant to Decedent 4• Probate Fees 5• Accountant's Fees 6. Tax Return Preparer's Fees ~. TR,4 v/' ~. /~ ~v4 o r1~~',e ,/>r,d/~t in//S TRH % i a ~ e a 5 ,-~- AMOUNT ~' S?, z e /3J, o v ~9d~~~~ SA o ~ . ,~ TOTAL (Also enter on line 9, Recapitulation) I $ /6~(, ~ V (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF s~wE~ru~E ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS D./~C / ~ Q . ~= /p/~~C.C/C FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimburse ~ 0 2 2 8 ITEM d medical expenses. NUMBER DESCRIPTION VALUE AT DATE 1 ~ OF DEATH /VDN~ TOTAL (Also enter on line 10, Recapitulation) ~ I /y d N r (If more space Is needed, insert addltlonal sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA S~~E~VLE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF 0 ~ ~s ~_ ~P~,C,E/~' FILE NUMBER ~d ~ ~~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Do Not List Trustee(s) OF ESTATE Sec. 9116 (a) (1.2)] 1. ~/1i7~/!~'~' /' S Y~QT~ ,~ G ~ie.yA~ ~- ~aw'Ritl ~~~ ~ ~r'~°S ~U-2G' ~/,~ / X16 2. ~~° T~61~ie / G ~ °~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX iS NOT BEING MADE 1. /V D /V,E B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. /(/ 011V E Q TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ /~/ d N/ (if more space is needed, insert additional sheets of the same size) (~ Ct~s~