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Home My WebLink About12-27-101505607121 REV-1500 EX (06-05, ~~~I~IAL ~~~ QNLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PoBOx28oso1 INHERITANCE TAX RETURN 2 1 1 0 0 9 6 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 0 5 1 6 2 0 0 8 0 1 3 1 1 9 2 0 Decedent's Last Name Suffer Decedent's First Name MI D O B R I N O F F HELEN G (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 0 1. Original Retum ^ 2. Supplemental'Return ^ 3. Remainder Retum (date of death Q 4. Limited Estate ^ 4a. Future Interest Compromise (date of prior to 12-13-82) ^ 5. Federal Estate Tax Return Required ^ 6. Decedent Died Testate. (Attach Copy of Will) ^ death after 12-12-82) 7. Decedent Maintained a Living Trust A 0 8. Total Number of Safe Deposit Boxes . ^ 9 Liti ation Proc d R i d ( ttach Copy of Trust) . g ee s ece ve ^ 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 Kur t A. BI a k e 71 7 848 3Q,78 Firm Name (If Applicable) Blake & Gross, LLC First line of address 2 9 East Phi I a d e l p h i a St Second line of address City or Post Office Y o r k State PA ZIP Code n ~ _~_ REGISTER Q LS USE !ly~'Y ~~ ~ ~ ~ V) ~ rV `•3 .~ "~ ~ 3 a~~' ~' ~ ~ '"' t > ~ DATE FILED W ~,,} 1 7 4 0 1 Correspondent's a-mail address: Kblake4t~COfilCBSt. Under penalties of perjury, I declare that (have examined this return, ' udi aa:ompanying schedules and statements, and bo the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the I representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETU DATE 12/13/2010 ADDRESS c% 29 East Philadel hia Street York PA 17401 SIGNATURE OF PREPARER OTHER THAN REPRESENTA E DATE PLEASE USE ORIGINAL FORM ONLY r -~: m Side 1 L 1505607121 1505607121 J 1505607221 REV-1500 EX Decedent's Social Security Number DecedenrsName: HELEN G. DOBRINOFF RECAPITULATION 1. Real estate (Schedule A) .....:.................................. 1. 0 . 0 0 2. Stocks and Bonds (Schedule B) .................................. 2• 0. 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ........................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 0 ' O 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6• 7. Inter-Vvos Transfers & Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total-Gross Assets (total Lines 1-7) ........................... 8. 0 • 0 0 9. Funeral Expenses S Administrative Costs (Schedule H) ................ 9• 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 0 • 0 O 11. Total Deductions (total Lines 9 & 10) ........................... 11. O • O O 0 0 0 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• 0 0 0 ........ 14. Net Value Subject to Tax (Line 12 minus Line 13) ... ....... 14. • TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES T5. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 O 0 15 0 0 0 . (a)(1.2) x.o _ . . 16. Amount of Line 14 taxable 1 0 0 0 0 0 0 0 . at lineal rate X .o _ 16. . 17. Amount of Line 14 taxable O 0 Q 17 0 • 0 0 at sibling rate X .12 . 18. Amount of Line 14 taxable O 0 0 0 0 0 . 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 1505607221 1505607221 0. 0 0 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 10 0964 DECEDENTS NAME HELEN G. DOBRINOFF STREET ADDRESS 3819 Lamn Post Lang cITY HIII STATE PA ZIP 17011 Tax Payments and Credits: ~ • Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 3. InteresUPenalt rf Totai Credits (A + B + C) (2) y ' applicable 0.00 D. Interest E. Penalty 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT Total Interest/Penalty (D + E) (3) 0.00 Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. N Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 0.00 Make Check Payab/e to.• REG/STER OF W/LLS, AGENT ...P ., a~ ~ - ~ . _ a ...:.. .:__ . .. e"_... _n .. _ . LEASE 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 ocxurred after December 12,1982, did decedent transfer ~ ~ ~ ~ ~ ~ ~ without receivin ProPedY within one year of death g adequate COnsiderat10r'? ....................................................................................... ^ O 3. Did decedent own an 'intrust for' or payable upon death bank arxount or security at his or her death? ......... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benefidary designation? ........................................ ^ .......................................................... ^ X 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 a 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)J. 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 [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 disdosure of assetces and. filing a tax return are still applicable even ff the surviving spouse is the only benefidary. 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-0ne 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 (O) 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 2 P.S. 9116 a 1.3 . A sibli Section 9102, as an individual who has at least one parent in common with the decedent, whether b blood or n § ()( )J n9 is defined, under Y adoption. REV-1"502 EX + (8-98) scHEOVCE a COMMONWEALTH OF PENNSYLVANIA REAL ES 1 N 1 E INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 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 wining buyer and a willing seAer, neither being compelled to buy orseN, both having reasonable:knowledge of the relevant fads: Real property whkh b biMly~ovmed with right of aurv'norship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 0.00 TOTAL (Also enter on line 1 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT OF SCHEDULE B STOCKS & BONDS FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 All property jointly-owned with right of survivorship must be discbsed on Schedule F. ITEM I NUMBER DESCRIPTION VALUE AT DATE OF DEATH 0.00 TOTAL (Also enter on line 2, Recapitulation) I S 0 (If more space ~ needed, insert additional sheets of the same size) REV-1504 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDIJlE C CLOSELY•HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Schedule C-1 or G2 (including aq supporting infomiatbn) must be athached for each dasely-held corporationlpartriership interest of the decedent, other than a sole-proprie~rship. See instrucgons for the supporting lnfonnation b be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line (If more space is needed, insert additanal sheets of the same size) REV-1505 EX + (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHLD~lLE C-! CLOSELY-HELD CORPORATE _ STOCK INFORMATION REPORT ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Common Provide all rights and restrictions pertaining to each doss of stock. i 5. Was the decedent employed by the Corporation? .................................... . ^ Yes ^ No If yes, Position Annual Sal $ ~Y Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there tffe insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the pdicy 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years 'rf 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 Dopy 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 ~ 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 finandal 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 values. If real estate appraisals have been secured, attach copies. D. List of principal stodchdders 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 decedent's stock. State State of Incorporation Date of Incorporation ~P Code Total Number of Shareholders Business Reporting Year Produd/Service (If more space is needed, insert additional sheets of the same size) REV-1'506 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scHEOV~E ~Z PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 1. Name of Partnership Date Business Commenced Address Business Reporting Year City 2. Federal Employer LD. Number 3. Type of Business Product/Service State Zip Code 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 Iffe insurance payable to the paMership upon the death of the decedent? ........ ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ _ Owner of the policy 9. Did the decedent self or tr~sfer an interest in this partnership within one year prior to death or within two years ff the date of death was prior to 12-31 ~2? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage Vansferred/soid Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ Date 10. Was there a written partnership agreement in effect at the time of the decedent's death?........ ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's 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 decedent's death? ................. ^ Yes ^ No ff yes, provide a breakdown of distributions received by the estate, induding 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, induding a Schedule C-1 or C-2 for each interest. • • ~- ~ • r ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of tinandal statements or Federal Partnership Income Tax returns (Form 10115) 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 valuels. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. ^ No REw~ soy Ex + (s-as~ SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES IN R S GENT DECED NTRN RECEIVABLE ESTATE OF FILE HELEN G. DOBRINOFF 21 10 0964 All property jointly-owned with the right of survivorship must be discbsed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter On line (If more space is needed, insert additional sheets of the same size) REV-?508 EX + (8-98) SCHEDULE E CONMAONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned whh right of sun-Norship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 0.00 TOTAL (Also enter on line 5, Recapitulation) ~ S (If more space is needed, insert additional sheets of the sarrre size) REV-1509 EX + (&98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY ESTATEt~ FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Nan asset was made joint within one year of the decedent's date of death, k must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME A. B C JOINTLY-OWNED PROPERTY: LETTER DATE ITEM FOR JOINT MADE DUMBER TENANT JOINT 1. IA. ADDRESS INCLUDE NAME OF FINANGALNSTITUTION A 1D BANK AG:OUN7 NUMBER OR SIMILAR DATE OF DEATH IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET % OF DEG7S INTEREST TIONSHIP TO DECEDENT DATE OF DEATH VALUE OF DECEDENTS INTEREST TOTAL (Also enter on line 6, Recapitulation) I j (If rrrore space ~ needed, insert addrtanal sheets of the same size) REV-1510 EX+ f8-98) COMMONWEALTH OF PENNSYLVANIA INHERffANCE TAX RETURN OF sc~~ov~E INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE HELEN G. DOBRINOFF 21 10 0961 This sd~edule must be completed and filedrf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. UCJVRIr ~ IV17 yr rnvru~~ ~ ITEM u«x~~~T~~T~"~AnONSi#PTOOECEOFxrAra DATE OF DEATH 960E DECD'S EXCLUSION TAXABL NUMBER T~~~~E0.ATTAgfACOPYOFTIA:DEEDFORREALESTATE VALUE OF ASSET INTEREST pFAe~e~~ VALUE TOTAL (Also enter on line 7 (If more space is needed, insert additanal sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONVVFALTIi OF PENNSYLVANIA FUNERAL EXPENSES & INHERRANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 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 decedents address is not the same as claimants, attach explanation) Claimant 4. 5. 6. 7 Street Address City State _ Relationship of Claimant to Decedent Probate Fees Accountants Fees Tax Return Preparer's Fees Zip TOTAL (Also enter on line 9, Recapitulation) I = (If more space is needed, insert addifanal sheets of the same size) REV-1512 EX + (12-03) COMMONWFJILTH OF PENNSYLVANIA INHERRANCE TAX RETURN ESTATE scH~ov~E ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 0.00 TOTAL (Also enter on line 10, Recapitulation) I S 0.00 (If more space is needed, insert add'~tional 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 HELEN G. DOBRINOFF 21 10 0964 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ltst Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Indude ht spousal distributions, and transfers under Sec. 9116 (a (1. )2 ] 1. Gary L. Dobrinoff Lineal 100.00 3819 Lamp Post Lane Camp Hill, PA 17011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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. 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) EtEV-1514 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN ESTATE OF FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 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. ^ Wi11 ^ Intervivos Deed of Trust ^ Other ^ Life or ^Term of Years ^ Life or ^Temt of Years ^ Life or ^Tenn 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 - ^31/2% ^ 6°~ ^ 10°~ ^ Variable Rate °~ 3. Value of life 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 . . . .. . ... ............................... S 2. Check appropriate block below and enter corresponding (number) . . . . . . .. . . . ............... . Frequency of payout - ^ Weekly (52) ^ Bi-weekty (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ......................................................$ q. Aggregate annual payment, Line 2 multiplied by Line 3 . . . . . . ............................ . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6°i6 ^ 10°~ ^ Variable Rate °~ 6. Adjustment Factor (see instructions) . . . ............................................ . 7. Value of annuity - If using 3 1/2°~, 8°~, 10°k, or if variable rate and period payout is at end of period, ca~ulation 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 6) + 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 resuRing life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If nave space is needed, insert additional sheets of the same size) REV-1644 EX+(3-04) INHERITANCE TAX scHEOV~ ~ COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT INHERITANCE TAX RETURN RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 21 ~ o ossa I. ESTATE OF DOBRINOFF HELEN G. (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 all 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. n, 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 ............... S 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 Unincludable 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) In, INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) 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 ........................................................... S D. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . E. Taxable value of corpus consumed (Line C x Line D) ................................ S (Also enter on Line 7, Recapitulation) REV-1645a+(3-84) INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA X RETURN C T REMAINDER PREPAYMENT ELECTION Z1 10 0964 INHERITAN E A -ASSETS FILE NUMBER RESIDENT DECEDENT I. Estate of DOBRINOFF HELEN G. (Last Name) (First Name) (Middle Initial) I1. Item No. Descri tion Value A. Real Estate (please describe) Total value of real estate S include on Section II, Line C-1 on Schedule L B. Stocks and Bonds (please list) Total value of stocks and bonds S include on Section II, Line C-2 on Schedule L C. Closely Held S#ocWPartnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership S include on Section II, Line C-3 on Schedule L D. Mortgages and Notes (please list) Total value of Mortgages and Notes S include on Section II, Line C-4 on Schedule L E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property S include on Section II Line C-5 on Schedule L 111. TOT4L (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+(3-e4) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN FILE NUMBER 21 10 0964 RESIDENT DECEDENT -CREDITS- I• mate of DOBRINOFF. HELEN 11. I Item No. Total unincludable assets (include on Section II, Line D-3 on Schedule S S a Nome) Name) (Middle Initial) Amount 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 (pleose 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: 111• ~ TOTAL (Also enter on Section II, Line D-4 on Schedule L) I S (If more space is needed, attach additional 8'i4 x 11 sheets.) REV-7647 ~(+ (9-001 COMMONWEALTH OF PENNSYLVANIA INHERrrANCE TAX RETURN RESIDENT DECEDENT OF SCHEDULE M FUTURE INTEREST COMPROMISE NUMBER HELEN G. DOBRINOFF 21 10 0964 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 I. Beneficiaries NAME OF BENEFICIARY I RELATIONSHIP I DATE OF BIRTH I NEAREST B RTHDAY I ~2. I _I _ i I 3. 4. 5. II. For decedents dying on or after July 1,1994, if a surviving spouse exerdsed or intends to exerdse a right of withdrawal within 9 months of the decedents death, check the appropriate block and attach a copy of the document in which the surviving spouse exerdses such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also indude as part of total shown on Line 13 of Cover Sheet) ...... $ 3. Value of Line 1 passing to spouse at appropriate tax rate (also indude as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate (also indude as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also indude as part of total shown on Line 17 of Cover Sheet) ...... $ 6. Value of Line 1 taxable at collateral rate (15°~6) (also indude as part of total shown on Line 18 of Cover Sheet) ...... $ 7. Total value of Future Interest (sum of Lines 2 thti 6 must equal Line 1) ..................... $ (If more space is needed, insert additional sheets of the same size) REV-~saa Fx (~ ~-sa) m COMMONWEALTH OF PENNSYLVANIA SCHEDULE N SPOUSAL POVERTY CREDIT ABLE FOR DATES OF DEATH 01/01/92 to 1i HELEN G. DOBRINOFF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1. Taxable Assets total from line 8 (cover sheet) ...................................................................................... L 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) .. 6. SUBTOTAL (Lines 6a, b, c, d) .............................................................................................................. L6• 7. Total Gross Assets (Add lines 1 thru 6) ............................................................................................... 8. Total Actual Liabilities ............................................................................................................................ 9. Net Value of Estate (Subtract line 8 from line 7) ................................................................................... IIIW-e 9 Is greater than 5200,000 -STOP. The estate is not eligible fo Gaim the credrG K noL continue to Part II. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 a. Spouse ............................. 1a. 2a. b. Decedent ......................... 1 b. 2b. c. Joint ................................. 1c. 2c. d. Tax Exempt Income ......... 1d. 2d. e. Other Income not listed above ..................... 1 e. 2e. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1f) + (~ + (3fl 0.00 9. 0.00 (+3) 4b. Average Joint Exemption Income ............................................................................................................... - Hline 4(b) is greater then 540,000 -STOP. The estate is not eligible to claim the kaadit. M not; continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less :.................................... ~? ; 2. Mutiply by credit percentage (see instrudions) .................................................................................... 3. This is the amount of the Resident Spousal Poverty Credit. Indude this figure in the calculation of total credits on line 18 of the cover sheet .............................................................. 3• 4. For Nonresidents, enter the ratio of the decedent's gross estate. in PA to the value of the decedent's gross estate ........................................................................................................................ 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Indude this figure in the calculation of total credits on line 18 of the cover sheet .......... 5• REV~1849 EX +~(8-98) CONMAONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER HELEN G. DOBRINOFF 21 10 0964 Do not complete this schedule unless the estate is making the eled~on 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 eledion applies to the ~ Trust{marital residual A B By-pass Unified Credit etc.L If a trust or similar arrangement meets Ehe requirements cjf Sedion' 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 spedfically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilar 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 e~~rvivinn ~~,~~~ ~~n~pr a Sartinn 9113 (A1 trust or similar arrangement. - - -- -- --- -- - ~~~~ Value Part A Total $ Part B: Enter the descri bon and value of all interests included in Part A for which the Section 91 13 A election to tax is Mein made. Description Value Part B Total (If more space is needed, insert additional sheets of the same size) REV•1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: Discount: 0.00 Interest Table Year Days Delinquent this time period Balance Due this year Interest this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throw h 1991 1992 1993 throw h 1984 1995 throw h 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: _ '~~--- _~ ~Q - ~ ~ rti _~ ~M " ~~~~i ~~ '. Q. ~Qp ~/! ~ O ~Y.ry ~ i~ _ ~~. ~~` I~'=