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HomeMy WebLinkAbout01-20-11 (2)1505610101 REV-1500 Ex ~°1.1°' ~ PA Department of Revenue Pennsylvania DEPApTNENT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6ot Harrisburg, PA 1128-0601 RESIDENT DECEDENT OFFICIAL USE ONLY' Code Year File Number Date of Birth MMDDYYYY og3otR6~ Decedent's First Name MI ~ o ~s ; .~.~ ... L Spouse's First Name MI a~~~ ~aw~ tF n n. o~ J REGIS WILLS k1SE ONLY=- ; ~ ~-t. ~ , "~ -, "S~ "~"7 - .., ,. r~7 ,:.~ + ~.i First line of address ~ ~ ~~ ~ ~ ~"; _~ G~ `' 1 ~ C h d i n r a s r-- '~ ~' ;~; -- ~ ~1 ~, - , ~~ Second line of address ~-~ ~_ , -= ~~ ter.>>. .~,,.x /// :a.:; ~ City or Post Office State ZIP Code - DATE FILED M: C ~~h. ~ n i C s. b v'~ ~- ~ u4 ~ ~~7 ~ 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. SIG URE OF PERS N SPONSIBLE FOR FILING RETURN DAT ~~~ AD RESS SIGNATURE OF PREPA OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: ~ ~ ~ ~ 6 ~ ~ ~ l~ RECAPITULATION 1. Real Estate (Schedule A) ................................... '......... 1. Q'+~: ~ Q ~.:,... 2. Stocks and Bonds (Schedule B) ..... ................................ 2. ~~ ~ 0 _ .,. .:: f ,aka .: ,~ , ~ , ~'la;~" r~ 3. Closely Hetd Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~ ~ d }' a-,~ 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ~ Q r. .-, ~ d: 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ ~ ~ ~ 1 ~y 6 -. .- ~ z.; ~. ~ ~;~ 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. ~~ - ~ _ ~ ©~ 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property '~ ' ' ~ ~ ' '~~ "~''~ fi (Schedule G) p Separate Billing Requested........ 7. ~ ~ ~ ~ ~ ` ~;: ,~; -~ " ~. ~- 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. Z, ` Q ~ ~ ~, -l 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. L~. ~j 6 Q ~ ~ r 6 .: ~G 10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I 10. d ~ ., 9 9 ( } .............. 4 ~ ~ ~ %~ r . , - tea, 11. Total Deductions (total Lines 9 and 10) ................................. 11. 2 ~ ( ~f 7 1 ~~y~,~ 1 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ Z, ~- ~ 5 ~ ; ~ ,~ ~' 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~`~"' '~'~', ~ "- an election to tax-has not been made (Schedule J) ........................ 13. t7 ~? ~'~ .~~~ ~4.. 14. Net Value Sub'ect 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 ~ ~ ~ ~ti (a)(1.2) X .0_ ~ ~ Q Q 15. r~ 16. Amount of Line 14 taxable - at lineal rate X .0 _ _ Q .,~- (~ ~ 16 ~`~ ~: 17. Amount of Line 14 taxable at sibling rate X .12 ~ tip; d ~,; 17. ~ ; 18. Amount of Line 14 taxable K ~`~ ''''~a ~ ~"~' ~" ~'"~'~` ~, ~ L ~~ ~~' `"~~`'~ ~"~ ~` r '~ t ~ ~ at collateral rate X .15 ~ ~ ~ ~ ~ , 18. ,. ~ {_ , y 19. TAX DUE ...................... ................................... S 19.` < ~~~~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 155610105 J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME STREET ADDRES CoIlO ss CITY anc ~~ STATE ~ ZIP t Pfd- ~ t d5o 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 oval on Page 2, Line 20 to request a refund. (1) ~•Oa Total Credits (A + B) (2) 6• b (.~ (3) O.Od (4) 6 •oa 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~. ~~ 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? .................................................................................................................. ...... ^ 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 f 72 P.S. §9116 (a) (1.1) (i)j. 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) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Troy ~-~x~~e~s~ 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 TOTAL (Also enter on line 5, Recapitulation) I $ ~` ~ ~ i ~J l- (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCI~IEDVLE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Crc~[rrt~i,r~ ~ ~isi{xb`~+, $~%~nce , ~~~ ~~ E~P~us ~~~. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address Citv Year(s) Commission Paid: State Zip 2. Attorney Fees 3. 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 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. _ Zip TOTAL (Also enter on line 9, Recapitulation) I $ ~5(~ ~- (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size)