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Home My WebLink About08-20-1015056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year Fle Number Bureau of Individual Taxes INHERITANCE TAX RETURN t PO BOX 280601 '~ ~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~-~ ( ~~' ~~ ~ ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix DecAe~dent'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 8E FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~lr 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A;I between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS 8ECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Firm Name (If Applicable) -,,`_} {' r,-;~~ REGISTER OF,~~S~ USE ONL-'if-~ ,... t~ a .: _, ~; :_ ~ h7a Firfst line of address ~+ `~ ~3 7 ~ '~ U ~ ~ ~ KGB 2 ~~~ Second line of address ~ ~ , ~ 'T! r ` ---~ __ ...; w Ciry or Post Office State ZIP Code oq~FILED~~' ~ } 4w. ) Correspondent's e-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 co-nplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA OF PERSON RESPON BLE FOR FILING RETURN DATE ,. SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIti1NAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1 R l t t h d l A S 1 - ~J /( . ) . ............................................ ea es a e ( c e u e . , 2. Stocks and Bonds (Schedule B) ....................................... 2. ~~ ~( 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~~ ~ 4. Mortgages 8~ Notes Receivable (Schedule D) ............................. 4. / ~ ~ I'l ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. „~ ~,> (J 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. a'V U ,t 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. ~~ R ,~ 8. Total Gross Assets (total Lines 1-7) .................................... 8. ~~ ~~ 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. ~) ~ ~ ~~ 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. ~~ n ~ 11. Total Deductions (total Lines 9 8 10) ................................... 11. ~~~ '~ / ~e 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which h h l S ~ an election to tax as not been made ( e J) ........................ c edu 13. ,, 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX COMPUTATION -SEE INSTRUCTIONS FOI2 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 15056052059 Side 2 15056052059 . - ..~ l _ .x. -r - . ~ pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. REV-1500 EX Page 3 File Number Decedent's Complete Address: (3) , ~~ (4) (5) --~r (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. 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? ........................................................................................................................ ^ (~ DECEDENTS NAME ` DECEDENT'S SOCIAL SECURITY NUMBER STREET ADDRESS `~ `~ ~ t~l ~~ ~ - - -~ ~~ t~ c~_~ __1~ vc~_c~ ------ ---T ~ ~-- -- _ -- -- CITY STATE i ZIP C~~rl ~51~. ~ ~ ~c71~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit __-_ B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) ~. Total Credits (A + B + C) (2) ,,~~ otal Intere enalty (D + ) 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. 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 ar 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)]. }n r Fnr }hn n F }hn ~n.r nnn.,nn ~ ((l1 nnrnnnt or dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers tV 'rrll IVI uIG usG iJl UIG JUI Y~YIIIy JwUJG Es zero ~V1 ucilsGF14 [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exem~ a transfer to a surviving spouse from tax, and the statutory requirements ivr disclC~sure elf assets and filing a tax return are s6A applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 200C: P a____S___ 2-_.y J L:3-1 a...._ ! a J__aL a_ S_- aL-- S ~ a..-_i t tax rate imposed on the net value a~ tti3!l~lCt~ !!tJ!!! a 11~i'ts$ctj~41 !;1!!!L4 t1N~!!ty-tl!!C yC~rJ U! 1gC Car yL3tlSEt~4.Cr t!! 41C~!It lL3 3Jr r:JS t!!t' IJ~C t!S ~ ~!!U!!t1! ~rG~!!C, ctt! adoptive parent, or a stepparent of the child is zero {0) percent [72 P.S. §9116(x)(1.2)]. }nv # "mn rr }h nn+ I~~n f }inn }n n f r }hn f } r7 n nn}~n 1~ nn( fini rinn n fn~.r r! nn hnlf lit C: ! - -+ 2 e IQ/1 ra t~. II IIL/I~SGU VII t11~. IIGt VaIUG VI trQllsfels tV Vr tail UIG U.~e V! if l~. Ue~G11LJ Itr{GQi ~n'~.11t~1~11GJ iJ IVUI ~IIU VII .~IICiII tY,J! f~.rl~il it, rG~Xt~1Jt ~~J IR%t~iU t!i 72 P.S. §9116(1.2) [72 P.S. §9116(x)(1;]. - ,. .. -,-.: - f ,- , --.. .. ,.- - .:. ,-,. ... - - 3i¢' ,.`..`. iiPti ~i2' i38t;cili ~i2 ?~' ~9 i i •-.~: i ~ "vi"iii:i 'S 3~a -'ii 1(i8 .>. - -. - - -.-- ,.- , _ti.~.~:;~ v uiiiiuJ w iivi 3 1 ,J. ~t 6ia 1 ..iia. rtSl 1 1 ~ i' iris . ur r ... :.+~,t3zJ3. ? 3i,L. ..:~~ u...: ,~.:i'; .... s..:s'. 'iy ... :.-?~ •?S 3~~_. L~~Sv ~16S wit, !1S !,'~.J; 3!l Sl+.1?S YVl43! .!!~ 4'1e:,'Srd$l9t, v-1~ether by blond or adoption. y .. .. y . REV-1508 EX+ (6-98) SCNEDIJLE E COMMONWEALTH OF PENNSYLVANIA C~`"'~SH~ BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~ f FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F, ITEM VALUE AT DATE NUMBER pDESCRIPTION OF DEATH ~rrr`S ~ v~- r~ F ~ l 7~ ~ ~ ~' ~ Y8'~ ~- ~ TOTAL (Also enter on line 5, Recapitulation) ; I ~~~~'~~~~~~ (If more space is needed, insert additional sheets of the same size) -.5.. _~~. .. ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF ~~ ~ FILE NUMBER ~ _ Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 5t~, ~ ~ ~~Sc~ . ` ,~' Sc~Jo N2~S~ ~~ t" ~~. ~o • B. ADMINISTRATIVE C05TS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) ~~ i ~ ~ ~ U~ Q rS ~irt-n ~ t`~l ___ / J `-, Street Address _ ~3 ~~ ~ + 1-1a ne ',l e r :_.-~' City ~ ~ r,_~ S l ~ State ~1~ ZIP ~_ ~~~ Year(s) Commission Paid: 4l_V1,. o~--C~ ~ ~ __ 2 3 4. 5. 6 7. Attorney ~ees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees; Accountant Fees: Tax Return Preparer Fees: ZIP TOTAL (Also enter on Line 9, Recapitulation) I $ S~ ~~ ~~o ~ If more space is needed, use additional sheets of paper of the same size.