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HomeMy WebLinkAbout08-20-10 5056051058 REV-1500 EX (06-05) SE ONLY L OFFICIA U PA Department of Revenue County Code Year File Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 ~ { Q ~ Number r ®~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth _._ _ __ L i .- ~~_ 13 ~`~ ~' ~- ~~ r dtc~o ~ 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; I `'J ~- 3 0 ~_ ~{~ 6 ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW y"µ°`' 2. Supplemental Return ~ `;"""";n} 3. Remainder Return (d ;~!~" 1. Original Return ..,,,,.,, ate of death prior to 12-13-82) 4. Limited Estate .,w..,,, 4a. Future Interest Compromise (date of ~.m.:;;,~~- 5. Federal Estate Tai: Return Required death after 12-12-82) 6. Decedent Died Testate ~;"~ ,~; 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes K' (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) 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 - _ _.. ~. .: Firm Name (If Applica le) ___ _ REGISTER O~V~II7L5 USE O{ . `: ~C' ~~ . ~ i T'1 t^., 1 ~i First line of address ~" Ir- ... . , ... .. _. -=, ~.. .~ ,, Second line of address :~7 ~ ~ ,_ , --i • . =~ '~, .' 7 1.,., 3 c.,r~t - _ _ _ DATE FILED ~ City or Post Office State ZfP Code _.. _ . _ _ _ ......__ 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. SI TURE O PERSON RESP SIBLE FOR FILING RETURN DATE A DRE S ~ ~~ t ~ U ~ ~ ~ s~ ~.~L~ ~t 5 ~~ ~.~,~N~ a SIGNATURE O PREPAR -R OTHER THAN REPRESENTATIVE DATE AD~3 l rQ~.CI~ ~~ ~ ~ ~.~, i~Na ~a ~,~ t ~)a 2~ PLEASE USE ORIGINAL FORM ONLY 15056051058 Side 1 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number ..~. n Decedent's Name: -~°~~'~/'~ `~ ~e ~~a ~~ ~ I,J ....~._w..~.~..~.~.aar.._.~~..~.~.r .........~~. _.. . . .._. ... . ~ ~~ y ~ ~- 1 ~ ~ .~ u ~ . .m . ~~..~....~~.~„m_~. .__.~..r_~~~~ ~...u_.. RECAPITULATION ~ .~..~. .._ ._m~..d~... ...... ......_......m..~ ....._ ~~ _~..d~.....~.ti..., 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. ' QUc7i Gv ~ 1 . 6. Jointly Owned Property (Schedule F) ~~";°M~ Separate Billing Requested ...... . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~m.~ Separate Billing Requested....... . 7. ; 8. Total Gross Assets (total Lines 1-7) ............. .. ........... . 8. 6 ~ p-~~p r.~ 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 "" an election to tax has not been made (Schedule J) ....................... . 13. 14. Net Value Sub'ect to Tax Line 12 minus Line 13 1 ( ) ....................... .14. ~ ~ . CJ'D~ ~ Ott TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or _. ___ trans ers under Sec. 9116 (a)(1.2) X .0~ ~j ~~ L~ . Cr0 15. /~ l.J 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 _ _ _ _ _ 1 g. 19. TAX DUE ........................................................ . 19.' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~;~.~;; 15056052059 Side 2 15056052059 REV-1500 EX Page 3 r)p~prlpnt's Complete Address: File Number, ,.. .~..~~_.---- - -----r---- - -- - ~..,,. _..... __.. DECEDENT'S AME (( DECEDENT'S SOCIAL SECURITY NUMBER ~, ~l9 ~© ~~ ~ L..1 ~. L'~i STREET A DRESS ~ 3 s ~~ x.16 ~ -~-~- ~~ ~-~. CITY ~ v j~ STAT ~ ZIP Tax Payments and Credits: 1 1. Tax Due (Page 2 Line 19) ( ) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount ------ Total Credits (A + B + C } (2} 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (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. (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 t*o: 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 ^ N~o/ u a. retain the use or income of the property transferred :............................................................................. ............. ^ L`J 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 ..................................................... uate consideration? i de i h t i ............. ^ ............................................ v ng a q rece w t ou ? ^ . 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 far 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.~)]. A sibling 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-1508 EX+ (6-98) SCFIED!!LE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT 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 right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH f ~ ~ ,~c-~ G~ f~ C~av ~ ~O , `~'~t'1 ~ ~jr4~ ~ Y ~~ ~,-a ,~~dU i~c~ ~ ~G K, ~~e C,~S ~. "~ ~©~ `~ ~ ~ 6 ~~..~.~ ~,~~ ~~ s~.~ Qom. ~a~G~-~~~.~- Y la. ~'~ ~'° TOTAL (Also enter on line 5, Recapitulation) a ~~ ~d0.00 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY ~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] FILE NUMBER RELATIONSHIP TO DECEDENT I .AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE p//d U~~ ~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET [[ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size)