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Home My WebLink About07-19-10,~ J REV-1500 EX (05-04) PA Department of Revenue Bureau of Individual Taxes Dept. 280601 Harrisburg, PA 17128-0601 15056041046 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICUIL USE ONLY Code Year File Number Date of Birth •uu~r nee/ ~i9 / Decedent's First Name MI I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Mt ~, Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum O 2. Supplemental Retum 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 Retum 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 T0: Name Daytime Telephone Number 8 A R e >~ R~ R t? A R E Y ~ w~~ ~,.: ~ > 3 7 ° 7'° 6 Firm Name (If Applicable) ~scxa - xaas=~«m~;a~:- REGISTER OF WILLS USE ONLY Correspondent's a-mail address: ~Q,1/ C Under penalties of perjury, 1 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. DeGaration of preparer other than the personal representative is based on all infonnatlon of which preparer has any knowledge. SIGN URE O ;!PERSON R1E9S~P~O ~IB,L/E~FOR FILING RETURN //-'' ~7 DATE ADDRE~ S(J ~ (/JC7j!ji%wLiC,af (~~?iYlrif~ /~GC~ ~ ®~ ~ /O / SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE O DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J REV-1500 EX Decedent's Social Security Number RECAPITULATION erx?q~ wwq~pwwxu x ~aa a ew 1. Real estate (Schedule A) ........................................... .. 1. 1 ' ~ ~ I O n ` 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ 6 4. Mortgages 8 Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank De osits 8 Miscellaneous Personal Pro a Schedule E P P ~'tY ( ) ..... 5. .. . ~ ~ S 6. Jointly Owned Property (Schedule F) C Separate Billing Requested .... ... 6. ~ 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property Q (Schedule G) t= Separate Billing Requested..... ... 7. 8. Total Gross Assets (total. Lines 1-7) ................................. ... 8. Jr f 9. Funeral Expenses 8 Administrative Costs (Schedule H) .................. ... 9. ~ 0 ~ ~ ~ 10 ~~ 11 T / ( // 'T / W 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............. ... . 11. Total Deductions (total Lines 9 8 10) ................................ ... 11. ' ' + 3 S 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. '. 13. Charitable and Governmental BequestslSec 9113 Trusts for which ~~ii ~/ an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to lax (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 (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 17 18. Amount of Line 14 taxable at collateral rate X .15 18, 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056042047 O Side 2 15056042047 15056042047 \ \ ~ ~ IA \ ~ \ ~ \ \ w w w \ \ \ r A r A r A r w ~ r A r w r r ~-.~ r ~... r \ = \ ~ \ ~ N V N V N V \ N \ N \ N \ ~ N N \ N \ N \ N \ N \ N N NN \ N \ N \ O pQ o pQ ~ pp pp 8 8 pp ~ 8 ~ pp S QQN l 0 lO l~ lD lp lp l~ ~p ~p ~O `~+ lp lp l0 C ~ d d O ~ ~ ni ~ Or A n A ' G ~ ~~ N W G ~ m O ~ n N fp d V1 e~ -p a ~ 3 ~ ~ > > ~ y C ~ O ~ O ~ t p o = a D v' ° -o .6 ~ y 2 ~ ~ ~ • °' W y d Ro ~ m ~ ~ 2 a ~ _ n ~ c ~ ~ `" ~ ~ d O f D D I f T j d Vf 7 (D 3 d ~[ ~ F ~ fp ~ ~ ~ ~ 'Z '~ m ~ .°1. _ ~ m w ~ ~ '^ ~ i ~ ^ ,~ '~ 'r ~ s ~ 3 ~ ,r- ~ m C j fp vii ~ X 00 ~ _ ~ i/? t/1 {A N ! N r N W A ! V 00 W N N A lJl V1 V l0 V l0 iA iA iA d w N A r A I p I A W v N v A p ~o w to ~ ~ ~ r ~ ~n r n 00 0 0 ~c ~ 3 o ~ fD I to to m to in ?~ v+ :-' v, x 0 w ~ ~' ~ o i v o ~ ~ ° o o a A 8 8 g 8 o V o S ~ ~ o ~ i , r r r r r r r r r r r lD ~D 00 00 00 N r r O O O `O tp 00 C~ r A W ip iD W N V V Q1 in in l0 Oo V O A W A t0 O~ Q~ r to A A 00 V 00 V V to A to v+ v+ o 0 o m ' m y, m r r rn v, r v ~ m rn m o, m o~ r w w w w :p V v ~.+ :p m 01 01 Q1 Q1 O1 O1 r r r N V V V V 00 Vt ~ ~ ~ N i N {A V N i V R A A H t!i ~ N l0 t D ~' N ~ 00 T ? r V V O V1 01 W 01 to r w ~ ~ ~ v v i--~ oo w A t n to +n to ! T O I ~ Vt OO t o O S p O O p O p O p O I d ° ' ~ ~ ~ s N O I i/~ O Vii N 00 O O ~ S ~ w !'' l0 r 00 A lD A r N H A OAi O p O v W O O O ~p N i Vv O REV-1502 EX+ (6.9a) scN~ou~~ a COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Azl°tf ~~ p s G~ATZF2T All real property owned solely or es a teruM In common must be reported at falr market value. Falr market value is defined as the price at which property would be exchanged between a willing buyer and a wllling seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. REV-1503 EX+ (6-98) S//Cy~NEDpULE B COMMONWEALTH OF PENNSYLVANIA STV.,KS O[ BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All properly jointly-owned wfth Nght of survivorship moat be disclosed on Schedule R (n more space is needed, insert additional sheets of the same sme) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpYLE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions far the supporting information to be submitted for sole-oroorietorshios. ~~~ nixie space is neeoeo, loser[ aoamonal sneers of the same size) REV-1505 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business ProducVService 4. xr ~ ~ i 3 9 ~~` i ~~ i i; t~ ,~ 4 r ~. ~ Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7 Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $_ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • •- ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedents stock. ^ No (If more space is needed, insert additional sheets of the same size) REV•1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpuLE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER /~LPff-iG/~ .T.~'LfITZF2T 1. Name of Partnership Date Business Commenced Address Business Reporting Year City State Trp Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedents death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedents partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedents death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • •- • ~ A. Detailed calculations used in the valuation of the decedents partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market values. If real estate appraisals have been secured, attach copies. ^ No D. Any other information relating to the valuation of the decedents partnership interest. REV-1507 EX+ (1.97) scNEOU~E ~ COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF L P,~ ~~- o .i ~ ~1 H-TZ~2r FILE NUMBER All property ~olntly-owned with right of survivorship must be disclosed an Schedule F. (If more space is needed, insert additional sheets of the same size) ~V•7508IX. (t•97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY FILE Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly pintlyownad with the right of survivorship mutt be dkcbsed on SehaduM F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~1~°tf/G D 6L~9-7~Z~IZ7`, ~ /o`~ y,~S, ..~./YEo ~¢-~"- ~f/y£ W o O ®S %~C-~.`!~ `~ ~~ L l ~S/StFfl ~ /(//.~.Y ~C rio ~', ~o.~ a o 8 . ,$hL~ f~.~'~ y4 ~US~, -v4 G'~/z, ~tlD f=Ur~.v/'T~~~ lt/O ,r{~USEr~bG t' ~~~ -- a,v ~ y '~~'~ ¢< a n~ i~t'i ~-~v PF,e s6.~~ L / ~-E,vs . /r _ ~/ .~ ~ Pa%K /3 s~iart~ o / f" g`~i 3 ~~ 6 ~ 9 ~/..3 8/d . -S'T ~ ~6a ~- ~~ TOTAL (Also enter on line 5, Recapitulation) I S ~i ~~~' ~ (If more space is needed, insert additional sheets of the same size) r+~v.,ws~.u~n SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER K an asset was made JoIM tMthin one year of the dsaderd's dab of death, k must 6a roported on Schadub G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ~~~~ B. C. JOINTLYAWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name d financial insfilutbn and bank account number a similar idenfilyinp number. Attach deed fa Idntly-held red estate. DATE OF DEATH VALUE OF ASSET 96 Of DECJ)'S INTEREST DATE Of DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL,(Also enter on line 6, Recapitulation) I ; more space Is needed, insert additional sheets of the same size) REV-0S10IX•U9n ' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER•VIVOS TRANSFERS 8r MISC. NON•PROBATE PROPERTY ESTATE OF R ~ ~~ ~ L ~ ~- ~'' L/~TZ t ~T FILE NUMBER This schedule must be completed and filed H the answer to any of questions 1 through 4 on the reverse side of the REV-7500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THETiUNSFEREE,THEIRREIAPON6HIPTODECEDENTANDTHEDATEOFTMNSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPIJCABLE TAXABLE VALUE 1. N~~ ~ TOTAL (Also enter on line 7, Recapitulation) I S nwre space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCNEpYLE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~P~lic o J ~~.~r'ZE~z7^' Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Pff-S toe .? FFF ~!G/2 £ «/ ~ 3 f" 1. OP~~/~i /~1vs~tG' ~'9 5d _ ~ ftKES/A~ G~~,r~L~ t/3Qy a,vo ,e./rE i.~r~eus,~r / 71 ~ ~h~ ~ ~-~ APO /~ E~ i~, P.q ~3a ~l ~ yFa-s -fl~,e~~R ~uvf~ ~ i,~~r~.s~~ s~.cviaPs o ~//l~Kf ~fi Crf NP /fiG L, ~A ~ gKfSIA£ C~,~+f?/4~y r/A.PKf~ E,vGt.~-di,vG' ~3Sa. Uv /~b~/G~1SSl.~~Ltf pi.v.~P~.6'OLL6ro/.UG G'.if•SF)¢//CE Fd~ A~/~N 7s'~SS ~~/v'~2 i`PLOC,~J F./LS ~/9'Fj"£~ ~ ~~~ ~ c Qo - ~ B. / ADMINISTRATIVE COSTS: g 1. 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. ~ 7ax Return Preparer's Fees 7 TOTAL (Also enter on line 9, Recapitulation) ; (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 SCI~IEDYLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER L ~,SGiL O J G~Y f~TZ F2r Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unrelmbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER ~L Ptfi~ O ~ GL.g7Z ~/ZT RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not LlstTrustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 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. ~~~ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. NQ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDYLE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Shea ESTATE OF ~ L /~~ ~L D J, 6'L f}TZCI27- FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of Ilfe estate (Line 1 multiplied by Line 2) ......................................$ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line B) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18 (If more space is needed, insert additional sheets of the same size) REV-1644 EX * (3-04) INHERITANCE TAX SCIiEDYLE L CoMINHERTANCETAXRETURNANIA REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for alt remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of Uninctudable Assets .................$ 4. Total from Schedule L-2 ............................................:.........$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(sj of Life Tenant(s) Date of Birth .Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recaptulation) REV-1645 EX+ (7-BS) INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) Total value of real estate $ (include on Section II, Line C-1 on Schedule L B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of CashlMisc. Pers. Property $ (include on Section II, Line C-5 on Schedule i) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/s x 11 sheets.) REV-1646 EX+13-e4) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- FILE NUMBER I. Estate of (Last Name) (First Name) (Middle Initial) II. Item No. Description Amounf A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) S (If more space is needed, attach additional 8'/s x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEpYLE M FUTURE INTEREST COMPROMISE n Rev-1500 Cover Sheet FILE NUMBER This Schedule Is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other L Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: N Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One O 6%, ^ 3%, ^ 0% ......................$ (also Include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (Ii more space is needed, insert additional sheets of the seme size) REV-1648 EX (1t-99) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER This schedule must be completed and tiled if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ............................................ 1 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................... .. ....................... 3. 4. Joint Assets with Spouse ................... .. ... ............................... 4. 5. PA Lottery Winnings .................... .......................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ......................................................:. 16. 7. Total Gross Assets (Add Ilnes 1 thru 6) ............................................... 7. 8. Total Actual Liabilities .............................................................: 9. Net Value of Estate (Subtract line 8 from line 7) .......................................... 9. It line 9 is greater than $200,000 -STOP. The estate is not eligible to claim fhe credit. ti not, continue to Part II. Income: a. Spouse ........... 1 a. 2a. b. Decedent .......... ib. 2b. c. Joint ............. 1c. 2c. d. Tax Exempt Income .. 1d. 2d. e Other Income not listed above ........ 1e. 2e. f. Total ............. 11. 2f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) _ + (3f) (+ 3) 4b. Average Joint Exemption Income ..................................................... _ if IinA d/hl iR nraafar fhwn Ad/1 nM - RTAP Thn oafatn is nnf nlinih/n Yn claim fhe crarlif If nn1 nnnlinun fn 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .................... . 2. Multiply by credit percentage (see instructions) 3. This Is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . .............................. . 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................ . 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet...... . Pan i 1. rn. ~: 2. 3. 4. 5. REV-16/9IX ~ (197) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE 0 ELECTION UNDER SEC. 9113(A) FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital residual A B By-pass Unified Credit etc ). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. Part A Total I $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. (If more space is needed, insert additional sheets of the same REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Lf ~i~,~ J-. ~t~~~fsZT - __ STREET ADDRESS fl~~ f~oo DS g>` Cf 49-2. ~-U,c/ ~~ 5~ L/S B U2,rJ Ra>t~ G'~f,Gi~ hz /C C l7 cY/ LL GFFiu~ ,`r.~~ o~~ivFic~o ya ,Dr~vC~ r~ ~r aso~ H~,r r"sr- ~~.yP ~i~c,t~~`z)~ CITY STATE ®~ ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty _- Total InteresUPenalty (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. (3) (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. (56) 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 "intrust 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)].