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Home My WebLink About01-13-111505610101 REV-1500 ~ ~°i_1°' ~ PA Department of Revenue Pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes INHERITANCE -TAX RETURN PO BOX 280601 __ Harrisburg, PA 1']128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW USE ONLY my Code Year File Number ,., , , Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First ame MI E a 4 W _ '?\j!IR I`VE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First N me MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW O 1. Original Return O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received '_ ~ ~ w :~. ~ ~ y R ~ THIS RETURN MUST BE FILED IN D PLICATE WITH THE REGISTER OF ILLS O 2. Supplemental Return O 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 O ___I_ O 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAXI ORMATION SHOULD BE DIRECTED TO: Name D ytime Telephone Number ,_ REGISTER OF WILLS USE ONLY ~ ~~ . .., ~? ~ ~. First line of address ~ ~'~ C7 r ~-,: ~, .: ~~ ~ Second line of address ~A-A ~ L.A.i `~' "^`' '~ ~...., _....... .v.ralen _ City or Post Office State ZIP Code tij t ~E FILED r, ?~-" Correspondent's a-mail address: i ~ ~ ~~ ~ Under penalties of perjury, I declare that I have examined thi eturn, including acco panying schedules and statem nts, 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 infor ation of which preparer has any knowledge. SIGN UR OF PERSON RESPO SIBLE FOR FILING RETURN ATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 ~~ J REV-1500 EX Decedent's Name: 1505610105 ecedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. a • 2. .... Stocks and Bonds (Schedule B) .................. ................. 2. +~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ,,, 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... I 6. ++ 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property ~ (Schedule G) O Separate Billing Requested........ 7. 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 Sub'ect to Tax Line 12 minus Line 13 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 i at lineal rate X .0 _ . 16. , 17. Amount of Line 14 taxable _9 ~ ~~ ' at sibling rate X .12 s 17. 18. Amount of Line 14 taxable ~ ~ .~;1 r~.t at collateral rate X .15 ~- 18. 19. TAX DUE ........................................................ .19. j ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~ Stde 2 15U56101D5 105610105 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S AME CA..1/Y~, '~. ~ e ~ / ~~/~ _ STREET AD~R s i ~ -- ~-1 ~sl~. ~~~ ~ d CITY STAT ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in ova! 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. File Number (1) Total Credits (A + ) (2) (3) (4) (5) ENT. Make check payable to: REGISTER OF WILLS, PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN TIDE 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 deat ? ........ ...... ^ ^ 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 d 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 tran 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 [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the staff 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 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 bens 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 [7. Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or to or for the use of the surviving spouse is use of the surviving spouse is 0 percent ~ requirements for disclosure of assets and to or for the use of a natural parent, an is 4.5 percent, except as noted in P.S. §9116(a)(1.3)]. Asibling is defined, under