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Home My WebLink About02-10-11~ 1505610101 REV-1500 Ex `°'_1°' ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania "- DE9ARTMENTOFREVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 '"~ r -~ arrisburg, 1'7128-0601 RESIDENT DECEDENT •~- ~ ~ __ ~-~ ~' ~ •~,~ TER• C E~,T INFO MATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name -Suffix Decedent's Ftrst 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 * - ~ ~~+ • ~ .• j ~ ~ ' ~ ' ' ~" THfS ~ETURN MUST BE FILED FN DUPLICATE WITH THE `;~ '~ ~'' ~~ ~` ~~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ ~ , :~,,, t~, Original Retur O 2. Supplemental Return t= 3. Remainder Return (date of death '- ~a ~~ ~~-<.,„~'~~~;J' ,~ prior to 12-13-82) O 4. Limited Estate Q 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required ~ ` . ~ `~~~ death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) *• ~. ~ ~~` between 12-31-91 and 1-1-95) (Attach Sch. O} CORESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: ,~ . Dame C`° '~`• ' ~ !``'~ Daytime Telephone Number f.r First line of address Second line of address .s.:_~. • City or Post Office -,3 +~- ~. State ZIP Code '+. -~ _ _ `,.. .y, ~ ~ '~!~!l+r~'Q-mail address: S~L~ ~ ~ ~ ~'' f s~ `;~ ~} __ ~~ Under penalties of perjury, I declare that I have examine 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 hats any knowledge. SIGIJA7~URE pF PERSON~ESPONSIBLE FOR FILING RETURN DATE= r ~~! `~~' 1 ADDR S `~- /~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE= ADDRESS PLEASE USE ORIGINAL FORM ONLY REGISTER OF WILLS USE ONLY c?~ T- .~., ~~ J ~ , .~ ~~ ~~ ~~ILEO i~ r ~ t 3 ~''C--~'. .. _... j Side 1 1505610101 15056101,01 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: _ ~ Y''1 ~ ~~"~p'r IZ-I~' .r ~ , r~~ ~ ~~~ l' ~ (_. ~ ~ ~ ~ ~ ~~ RECAPITULATION 1. Reai Estate (Schedule A) ............................................. 1. ~~ 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 Misc~(l~ti~a~r~~~~" b _d iy ,F~~..... 5. f- 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~ ~ -l 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested........ 7. ~ 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ ~ ~ (~~ ~"'r~'"~ 9. Funeral Expenses and Administrative Costs (S~hedule H) ................... 9. ~ ~ r~ ~ ~ .~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ~ 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. (~ ~, -,ems 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. ~ ~ ~ ~ Q, ~""' 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 tax le at lineal rate X ,~~ 2 d ''~ b Q , ~ ~' 7 16. ~ ~ , ~~ ~i 17. 1 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 O Side 2 1505610105 1505610],05 REV-1500 EX Page 3 Dpcpdent's Comntelte Address: File Number 2~^, ~ ' ,., C-~ (~~C~,`7 3 DECEDENT'S NAME STREET ADDRESS ~-'2- ~'~S:T~E'r'J~S -~_- - - -- - _ -- _--- --- - - -_ __ - _ - I - CITY STATE 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. 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) ~ ~~~ d~ (3) _ (4) 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 fife 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 [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 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 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)]. 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-1503 EX+ (6-98) r -~ SCHED~lLE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (Ii more space is needed, insert additional sheets of the same size) REV•1508 EX + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INhERITANCE TAX RETURN PERSONAL PROPERTY RFSIf1FNT f1F('FnFNT ESTATE OF FILE NUMBER A-17--C-~ l~- iIZ ~T ~ G1~~'I ~13~',~, c.~ 2C1 ~ (~ C~ C~C~ 1 _3 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 `~ ~~`'n ~o ~~ i s ~ ~- ~,1~~C,~lLM tGS~vi-c ~ ~ ~~ C~~ ~ ~ ~_~c~ I.1~ ~' ~ ~ ~ 2~~ h ~f~ (-QL~C ! /I SA-~ (~'1 C~ r^~~ ~ c ~'~~~ r~ ~ ~ ~~ ~~ ~~ ~ ~_ TOTAL (Also enter on line 5, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) ~1 `~'~ .~ ~~r~~ .'~ REV-1509 EX + (1.97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY 4\LJ~IJL~v i v~-v~v...... ESTATE OF FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME J ADDRESS RELATIONSHIP TO DECEDENT c ECX~1 CY, M I ~5 TJ ~7 r' ~C~ S ~~ j 7a.~r s,~jb-yy~ ~a.1Y1 : ~~ ~ f~ ®r2 --, ~ l (i.~.~ r ~ J 5' C~M JA-t-~ St'~ SF,c-.'c°~{~~'~ ~ f~ ('.c ~ ~ cam) ~'7~.f s~aMnte.-~ - r ~~ ~ ~j--~z i'~'eS, .~ e -~-~~ J h~ ;~-~~~ rc 5 r~ c~ 4 ~~~ ~~ ~~~~ ~ ~"f'~ - I h -1 ~-L~ JOINTLY-OWNED PROPERTY; LETTER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT 2 1. -•+~- 2. ~ ~~' r` 5 ~.i3 ~ A '7 A g, f~, )3 ~. ~ ~ 6 - [3 ~~ ~3 ~ tiw ~3 1~ ~3 a~~~g 1 C~ C? (j f ~~~' ~c,~ I CC 1'~ Z~r~ ~~~~ ~ 99+~ ~-~~ C DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. (1~'1 CM l~~S i ~~` ~r~~Q~ L~~-LCD ~c'~~~~k; ~) 1~~" ~ (Jt ~ ' S~ ~-^Q.cQc~ ~1LL,~.t~Y'1 (~Q-`~' 1'Fifd~-~~ ~ S~ ~l^~ ~~ ~~ ~~ Yt-L-crYl ~C P ~~f ~ c a~ /YI~M (~fzS ~ S~ ~±,r2C~1j(T- C,~.,~(~o ~~ ~~tE~~ ``~ i ~'~ ~~-'i ~f~ ) S~ C.~>~t T- Ls.l~ I d ,>v~ `fie r^l ~'~Cv- DATE OF DEATH VALUE OF ASSET C)F DECD'S INTERIEST DATE OF DEATH VALUE OF DECEDENT'S INTEREST r~~ ~ seI -~ /y /~ C r ( •C~~C C)C' ~~ ~~~~ ~- ~ r. '3 ~~ S~ -~ ht ~ ~ .c~`' ~~ ~ ~ ~ ~ - .~ ~. 7~ ,`mot ~,~,/ 3 ~'3s,-~ r / ~;,G::(nf ~' ,' S~C_" ~ ~ ~~ i .~~~ 7 ~~ a ~ ,~' TOTAL (Also enter on line 6, Recapitulation) $ ~~~ ~ C~ ~ ~ ~ {If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) ~~ SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER M~~L-~~12~ 1 C C~~An'la~~ LLB °~~~ 1-~ ~ n n'7 ~3 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ ~-'~j~ ~. ~'`~ f t~e~'1 ~-'~~~'`n~ C'I`E. 1. ,Vl , /-~}y'v'1 S <rY- ~~.~J P~~c~~ SQ~f J n -~~ h~ I ~'-'7 r rJ ~ ~? ~` Q.' $ f ~' C` .~cc ~) C^c_~ y}'l E' t f'y` .~-F~ ( / ,~"^ C~~~, ~ r_.~ S'F • r~•f CL_ 3 ~1 ~ `~ --- c~ct ~ Ic~:~ ~- c~~,~.$~.t ~-~E~.-~ ,, ~r. a ~ ~~ ~= I c~,;=~ t c ~. s-> c~t~ ~~~ r° E'vi~ -''pt~i rl C~1t~~r~t ~ ~S~C~'~~,' - ~F.c~~1 ~ ~ ~ ~ ~Jr ~ ~ C1 ~ c ~ ~ ~ ~-- L~.' b1 C ~ E f~L'1 ~ J t~1 ~`~' ``, c r } 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 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 ~. ~? ~ ~" ~+, cP TOTAL (Also enter on line 9, Recapitulation) $ ~l ~C (If more space is needed, insert additional sheets of the same size)