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Home My WebLink About08-26-101505610101 REV-1500 Ex ~O1.1°' ' PA Department of Revenue Pennsylvania OFFICIAL USE ONL`f __ DEPARTMENT OF REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi ~ ~ ~ ~~ Harrisburg, PA 1128-0601 RESIDENT DECEDENT ~ J, ~ ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return p 4. Limited Estate Q 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return Q 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder R:eturn (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number y First line of address Second line of address City or Post Office State ~~~ ~• ~C~ !r ~ ~ ZIP Code ~ 1~~~ REGISTER 01= 'WILLS USE ONLY' r. ~, f..~ ~ p J ^'r'+ ' ~ ,:.. ~..' ~e ,[I~fE: FILED ~'~~ .I ~ :~ ~ ` •~ ? ~t 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN --~ ~A~DATE ADDRESS SIGNATURE OF PREP RER OTHER THAN REP ESENTATIVE ~ -® ~ ~ DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J ~~ J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: h ~ ~ . ~ C(~ ~ ~`' ~~ ° ~~~~~~~ RECAPITULATION r 1. Real Estate (Schedule A) ............................................. 1 `y r~,. H ,~ ~ ~} F ~ ~~ ~, 2. Stocks and Bonds (Schedule Bj ....................................... 2 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3 r ~ 1 ~ y 4 4. Mortgages and Notes Receivable (Schedule D) ........................... 4 ~ r ~~. ~~ ~~ ~ ~ x .. ~: , 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5 Y r g ,~ ~ "~' ~ 4; 6. Jointl Owned Pro a Schedule F Se arate Blllin R nested ....... 6. ~ ~ ~ ~; ~ ~ ~ ~` ~ ;~ Y P rtY ( ) O P 9 eq 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property `'~`~~`' ~ ~ ~ ~'`~° (Schedule G) O Separate Billing Requested........ 7. ~ ~ ~2 ~ ' ~ 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 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 Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX CALCULATION -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 Side 2 1,505610105 15056],010.5 O J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME ~~f~~'/~j ~ Q ~ rT~~ ~---~_ ~ ~ ~. - v"_- ~ _ _ ~ _ _ _ _ _-- -- _ _ _ _ _- __ _ __ - -- _ _ ...- -- STREETADDRESS --- - --- --- _ -~ __- Uv ~~-~-_ ~-~- ~~-~~~ -- - - - _ _ _ _ _ - -- _ _ - - -. -- CITY ;STATE _ _ ~ ZIP S'- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 1 ,~7<T~ ~ , ~!"! 2. Credits/Payments A. Prior Payments _._ ___ __ -i' B. Discount ~~ ~~~ A~ ~~~Q_~~i / l~ /' Total Credits (A + B) (2) (Q 7~ ~ ~~ 3. Interest 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) ~ ~ r ~~d ~ ; 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 Dec. 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? ........................................................................................................................ ^ L~ 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for thE~ use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 far 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 21 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 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 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 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-1508 EX « (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. 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 the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~~ 1 ~~~ ~ ~~ ~~G1~ .~.~5~ , ~~~ i1~~6-~0~~ ~+ a . ~~~ i C:h tVy YY~.~t`f ~ Can ~~ 3. db~l-t, ~~ ark- hws~ l~ ~a~ ns ~~ .~?~ 113. Q ~ ~ (.,11~c~ ~t ~~ k~ h~~c~ C3~~~-gac~~ ~~~) ~ (S"d - ~' TOTAL (Also enter on line 5, Recapitulation) I $ ~~~ (,}'~ ~~ ~~ (If more space is needed, insert additional sheets of the same size) PS E , ~~~~~~ ~~ ~~ ~~ ~ P.O. Box 67013 (717) 234-8484 (Harrisburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide) website - http://www.psecu.com ACCESS YOUR ACCOUNT ON THE GO WITH YOUR SMARTPHONE OR OTHER DEVICE. SIGN UP FOR PSECU MOBILE+ IN PSECU~HOME® UNDER "MY .MONEY." 00033165 1 AV 0.335 THEODORE W CHYLACK C/0 THEODORE J CHYLACK EXECUTOR 42 PINETREE DR AUpUDON PA 19403-2025 BALANCE I 0186XXXXXX I I PAGE 1 I 07/01 ID O1 REGULAR SHARES BEGINNING 07/13 PAYMENT: DIVIDEND ANNUAL PERCENTAGE YIELD JOINT OWNER FINANCE CHARQE EARNED 0.401 FROM 07/O1/1O,.TH:R000H 2~2 ,-turn xr~ ;, 070110073110 330067.90 43.41 330111.31 07/31/10 769.66 _,: ...:: ~;..:~'8 :;<:><~>~'~`8~<~>`' Vii:.>~~I. ,. DIVIDEND YTD: YEAR TO DATE 2.70 TOTAL DIVIDEND YTD: YEAR TO DATE 772.36 .:<. 065 4 ,. 033165 4033165 07/13 ID O1 REGULAR SHARES CLOSED DIVIDEND YTD: YEAR TO DATE REV-1511 EX+ (10-06) SCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF _„~..- ~ - FILE NUMBER Debts of decedent mus be reported on Schedule I. ITEM NUMBER A. 1 DESCRIPTION AMOUNT FUNERAL. EXPENSES: ~~~'jj~J ~ ~ Q~ ~- ~ ~~ v"' `r ~'t~~ ~ .~ 021 ~ ~ S~~ v~- 1 I Y ~-~ ~ , ,.rte . ~-~ ~1 ~ ch rr~ i c~ ~ , ~~, l ~~ g. ADMINISTRATIVE COSTS: ~ , Personal Representative's Commissions ~1 i ~~ X02 I, ~C~l o (.~' Name of Personal Representative(s) _!~~--- Street Address ~~~11i~~-~~- ~ ~~ ~=------------ -- City ~7 cJ~b~{ State ~~; Zip ~ ~ ~~_ _ Year(s) Commission Paid: __ cT~•' t ~ -___ -- --- -------- ---- 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 t'~~1 t~~,~ ~' ~'i~~" - `i ~ / Ou U.~~lld 5. Accountant's Fees ~(j ~,~~ 6. Tax Return Preparer's Fees ~d~~ ~ tm ~t€~-~ i'#~a~ J , ~ V~_-~tjy~ "~ "la ~'VI`~JJ~3'~- gat ~Yck,b*11 cr~~ ~`'~ ~ t ~.G~ ~lj ~ ~ !tit - aY +~t 1c3~ 9~ n~.` M rs~c~s~~-tip ~ C l ~• t~{~ of ~( -(w~ Ulf~+>,(~ ~ 6'-~7~- ~d ~. U~. Cff~t u~ ~ t ~c's7" 14,rM8+~ ~' ~ ~ C~~~ ~ ~(jJc~-~S~ r~s~-!~' ~c ~U°~ ~ ~~. L~ ~i~3-~~, , (~ ~p l ~ 7$~cr ~' c>rc 7 (~ t~ ~tti ~"1~t~ ~ ~ ~' -~- d1Ji~d~~ nr~ k'~ S~.t`~~~2,~ !~r 0 ~ v'tsfF oac ~/i~/IV `~ I ~(S , Jb ~ds TOTAL (Also enter on line 9, Recapitulation) $ ~ .3~ ~~ ~''~~ "7~ --~- If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT DEBTS OF DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER ~~/ L/ Re port debts incurred by the decedent prior to death which re fined unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH /~ ~ M ~ µ~ S ~ ~ ~ i~ G~ s ~~,~ ~ ~ P ~ ~ l P ~~ ( ~ ~ 1~U ~ ~ ~ ~ y ~, ~~r. ~ 3 ~ r~r~--g ~ " i l ~a~ ~ i.~~.. , ~ r~.c ~ v~~~~~ ~(-~~1~ rte. ~~, t~ Inc ~ -~- ~ ~ .~~._S ~=~`~-~ l~ dr~~ ~,~ ~ ~' ~ ~~- ,~ ~ 17 ~ Vii- ~ - S' ~:-h~~~--~ s~~~~ ~~~. a ,~-~~ ~~~ ~ ~ ~ '~ . ~~ ~`~ ~ ~t~~ -~ c~~~G ~~ ~ ~ 5 _ ~ ~ ~ ~v6. ~' P ~' ~u~.. ~Jwti-- , ~ TOTAL (Also enter on line 10, Recapitulation) $ (71 ~ ~ ~~~ (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 FILE NUMBER ~' ~. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.211 ~r~ 1..`~ ~~ , 1~~ ~ ~ L.TJ /c~ ~~ ~~~~ ~d,~e.t~ P~=~ ~ ~ ~ 3 ~.~,~` ~L c ~ ~~ s~ ~~ ~l ~ ,t~ c.LP ~.~' See ~~-f~ , r~ ~ 1 ~~'6 Y ~. k~ C ~,~ ~ S~ ~-S`~~ ~~ , ~«kl~s ~~. Sint l.~ , I~~,, ~ ~"a~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX 1S NOT BEING MADE 1. 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET' $ (If more space is needed, insert additional sheets of the same size) `~' ` ;, ~ t.x ~.~. q• ~~ ~ :: f ~`"~ y ~ ^~.;.? ,s~ ;'S? ;.~. Z ,~. .. ~~, 4:.2 cw ~ ~ <3 '? s ~ Q NI V ~P ~ ~-~ ~ ~, ~~ no. a V