HomeMy WebLinkAbout02-10-11
1505607121
REV-1500 EX (06-05)
PA Department of Revenue Coun Code Year File Number
Bureau of individual Taxes ~ b
PoBOx28oso1 INHERIrtANCE 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 Suffix Decedent's First Name MI
D O B R I N O F F ~---~ H E L E N G
(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
0 1. Original Return
O 4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-62) 0
7. Decedent Maintained a Living Trust _
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
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 TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
K u r t A. B I a k e 7 1 7 8 4 8 3 0 7 8
Firm Name (ff Applicable)
Blake & Gross, LLC
First line of address
2 9 E a s t Phi l a d e) p h i a S t
Second line of address
City or Post Office
Y o r k
Correspondent's e-m~il~address: Kblake4t~COmCaSt.net
State ZIP Code i
P A 1 7 4 0 1
REGISTER OF WILLS USE Q~INrY
C7 "~'
~ o ===
~- ~, ----
~,..~rn Q t
_G' {Aj ~
~_, ~} ~ "D
C7 L1 -17 ..,m,
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Under penalties of 'ury, ~clare 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 mple .,0eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PER O IBLE FOR FILING RETURN DATE
~' 12/13/2010
ADDRESS
c/o 29 East Phila . ~ treet York PA 17401
SIGNATURE OF PREP/~R~ft OTHER THAN REPRESENTATIVE DATE
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505607121
1505607121
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1505607221
REV-1500 EX Decedent's Social Security Number
Decedents Name: HELEN G. DOBRINOFF
RECAPITULATION
1. Real estate (Schedule A) .....:.
.................................
1. ~ • ~ O
2. Stocks and Bonds (Schedule B) ........................
..........
2. O • O O
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ........:............... 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ....... 5. O • O O
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous N Probate Property
S
h
d
l
G
~] S
Billi
R
t
t
d
7
(
c
u
e
)
e
epara
e
ng
eques
.......
e .
8. Total Gross Assets (total Lines 1-7) ........................... 8. O . O O
9. Funeral Expenses & Administrative Costs (Schedule H) ................ 9.
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............ 10. O • O O
O O 0
11. Total Deductions (total Lines 9 & 10) ...... ..................... 11.
12. Net Value of Estate (Line 8 minus Line 11) .... ............. ........ 12. O . O O
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. O • O O
TAX COMPUTATION -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.o _
0. 0
0
15.
0.
O
O
16. Amount of Line 14 taxable
at lineal rate X .0 _ ~
~.--f
~~ • O
O
1 g,
O .
O
O
17. Amount of Line 14 taxable O O O
O
O
O
at sibling rata X .12 17. .
18. Amount of Line 14 taxable O
O O
O
O
O
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. O 0
nw-iauo t1C Page 3 File Number
Decedent's Complete Address: 21 1o D964
DECEDENTS NAME
HELEN G. DOBRINOFF
STREET ADDRESS
3819 Lam Post Lane
CITY
Camp Hill STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 0.00
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits { A + B + C) (2) 0.00
3. InteresUPenalty if applicable
D. Interest
E. Penaity
Total InteresUPenalty (D + E )
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. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 +SA. This is the BALANCE DUE.
(3) 0.00
(4) 0.00
(5)
0.00
{5A)
(5B) 0.00
Make Cherk Payable to.• REGISTER OF W/LLS, AGENT
_ _ ~ _.
t .. ,.: G.3Y ~r, ~'~ ... t 'S.i.,'Y 1"i~~~. C}~? "s. .. ^':f °i'?~~ .7 ..~:~~? 3~`...~i r~.~ k:5: •:.'
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 December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ ^X
3. Did decedent own an "in trust for" or payable upon death bank arxount or security at his or her death? ......... ^ X^
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 ABOVEQ~UESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
,. ~ .. .. ;. ~,s;.e~5 .... 9 ::"~i4. '~_,;; ... s. -r ~,,..G.'``.i~....;i'~.".:3 ~:"•'Kf'/1.s'._..'..l°. ~ .'~-' ~.' ~, y~--:: :.H +rA'; x _fY ., ~,
For dates of death on or 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)).
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} percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemat 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 twenty-0ne years of age or younger at death to or for the use of a natural parent, an
adaptive 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 (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-15A2 EX + (6;98)
SCHFDtJLE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF 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 willing buyer and a wiAing seller, neither being compelled to buy or sell, both having reasonable-.knowledge of the relevant facts:
Real property which is Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~ • 0.00
TOTAL (Also enter on line 1 Recapitulation} ~ S 0 00
(If more space is needed, insert additional sheets of the same size)
KEV-1503 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
All property jointly-owned with right of survh+orship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATN
~ , 0.00
TOTAL (Also enter on line 2, Recapitulation) ~ ; 0.00
(If more space is needed, insert add'dional sheets of the same size)
REV-15C4 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
'INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
Schedule C-1 or C-2 (including all supporting infom~ation) must be attached for each closely-held corporationfpartnershipinterest ofthe decedent, other than a
sole-prop-ietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL (Also enter on line 3, Recapitulation) ~ S
(if more space is needed, insert additional sheets ofthe same size)
REV-105 EX + (6=98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
1. Name of Corporation State of Incorporation
2.
Address Date of Incorporation _
City State Zip Code Total Number of Shareholders
Federal Employer I.D. Number Business Reporting Year _
3. Type of Business Product/Service
4.
5. Was the decedent employed by the Corporation? ....................................... ^ Yes ^ No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? ....................................... ^ Yes ^ No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years
ff 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 copy 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 an interest in other corporations or partnerships? ...................... ^ Yes ^ No
If yes, report the necessary information on a separate sheet, including aSchedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete oopies of financial 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 value/s. If real estate appraisals have
been secured, attach copies.
D. List of prindpal stockholders 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.
SCHEDULE C-7
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
{If more space is needed, insert additional sheets of the same size)
Provide all rights and restrictions pertaining to each Bass of stock.
REV-15d6 EX + (g-00)
SCHEDULE C'2
COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP
IN RESIDENTEDECEDENTRN INFORMATION REPORT
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
1. Name of Partnership Date Business Commenced
Address Business Reporting Year
City State Zip Code
2. Federal Employer LD. Number
3. Type of Business Product/Service
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 life insurance payable to the partnership upon the death of the decedent? ........ ^ Yes ^ No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
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 decedents death? ................. ^ Yes ^ No
if yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? ................................ ^ Yes ^ Na
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, including 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 financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market values. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-1507 EX + (6-98?
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHED[/LE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
All property jointly~owned with the right of survivorship must be disclosed on Schedule F. 4
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1,
TOTAL (Also enter on line
(If more space is needed, insert additional sheets of the same size)
a
REV-15'J8 EX ; (8;88)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All properly jointly-owned with right of survHorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 • 0.00
.TOTAL (Also enter on line 5, Recapitulation) ~ E 0.00
(If more space is needed, insert additional sheets of the same size)
rtcv-iaoy EX + (5-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
ff an asset was made Joint within one year of the decedents date of death, it must be reported on Schedule G.
SURVNING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
B
C
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOIN7 DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANgAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTERESI
1. A.
TATAI /61cn antar nn lino R Rneanitnlatinnl I S
(If more space is needed, insert additional sheets of the same size)
REV-15; 0 EX + (6-88)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCH~DIJLE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERLY
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME Of1HETRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND
'~'E°"rE°F'R""sFER."'T"a""caProFn~EOEEOwRPFxEar"~.
DATE OF DEATH
VALUE OF ASSET
%OFDECD'S
INTEREST
EXCLUSION
nF"PPUC"e~
TAXABLE
VALUE
1.
TOTAL (Also enter on line 7 Recapitulation) ~ ~
(If more space is needed,lnsert additional sheets of the same size)
REV-15x1 EX+(t0,-06)
' SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8e
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT pECEDENT
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, Famiy Exemption: (If decedent's address is not the same as daimant's, attach explanation}
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5 Accountant's Fees
6. Tax Return Preparer's Fees
7
TOTAL (Also enter on line 9, Recapitulation) ~ ~
(If rrwre space is needed, insert additional sheeis of the same size)
REV-1512 EX + (12-03)
scH~ov><E i
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES ~ LIENS
RESIDENT DECEDENT f
ESTATE OF 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 ;
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (5.001
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
NFI FN C, r)nRRINnFF ~1 1(1 n9~4
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
j TAXABLE DISTRIBUTIONS (ndude outright spousal distributions, and Vansfers under
Sec.9116 a 1. )]
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.
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~
(h more space is needed, insert additional sheets of the same size)
REV-1514 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESfDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
~ TERM CERTAIN
heck Box 4 on Rev-1500 Cover Sh
ESTATE OF FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
This schedule is to be used for ati single life, joint or successive life estate and tens 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.
^ Will ^ Intervivos Deed of Trust ^ Other
^ Life or ^Term of Years
^ Life or ^Temt of Years
^ Life or ^Term of Years
^ Lffe or ^Term of Years
^ Life or ^Temt of Years
1. Value of fund from which life estate is payable ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$
2. Actuarialfactocperappropriatetable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,
Interest table rate - ^3 1/2°~ ^ 6°~ ^ 10°~ ^Variable Rate
3. Yalueoflifeestate(LinelmultipliedbyLine2) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Lffe or ^ Term of Years
^ Life or ^ Term of Years
1. Value of fund from which annuity is payable ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$
2. Check appropriate block below and enter corresponding (number) , , , , , , , , , , , , , , , , , , , , , , , , , , ,
Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12)
^ Quarterly (4) ^Seml-annually (2} ^ Annually (1) ^ Other ( )
3. Amount of payout per period ...................................................... $
4. Aggregate annual payment,Line2multipliedbyLine3 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
5. Annuity Factor (see instructions)
Interest table rate - ^ 3 1/2% ^ 6% ^ 10°h ^Variable Rate
6. AdjustmentFactor(seeinstructions),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
7. Value of annuity - If using 3 1/2%, 6%, 10°k, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ...........................$
If using variable rate and period payout is at beginning of period, calculation is:
(Line4xLineSxLine6)+Line3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$
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 resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18.
(if more space is needed, insert additarral sheets of the same size)
REV-1644 EX+(3-04) INHERITANCE TAX
SCHEDULE L
COMMONWEALTH OF PENNSYLVANIA
REMAINDER PREPAYMENT
INHERITANCE TAX RETURN
RESIDENT DECEDENT OR INVASION OF TRUST PRiNCIPA4 FILE NUMBER 21 10 0964
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 StocktPartnership ............... $
4. Mortgages and Notes ....................... $
5. CashJMisc. 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)
[II. 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 ........................................................... $
D. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... .
E. Taxable value of corpus consumed (Line C x Line D) ................................ $
(Also enter on Line 7, Recapitulation)
REV-1645 EX + (3-84)
INHERITANCE TAX
SCHEDULE L-1
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT
-A$SETS- FILE NUMBER 21 10 0964
1. Estate of DOBRINOFF HELEN G.
(Last Name) (First Name) (Middle Initial)
11. Item No. Descri tion Value
A. Real Estate (please describe)
Total value of real estate $
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 Stock/Partnership (attach Schedule C-1 and/or C-2)
(please list)
Total value of Closely Held/Partnership $
include on Section II, Line C-3 on Schedule L
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes $
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 $
include on Section II Line. C-5 on Schedule L
~t~• TOTAL Also enter on Section II, Line C-6 on Schedule L) $
(If more space is needed, attach additions{ 8'/z x 11 sheets.)
REY-1646 EX + (3-84)
COMMONWEALTH OF PENNSYWANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION 21 10 0964
-CREDITS- FILE NUMBER
1. Estate of DOBRINOFF HELEN G.
(Last Name) (First Name) (Middle Initl
11. Item No. Descri tion 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. Unpoid Bequests payable from assets reported on Schedule L-1 (please list)
Total unpaid bequests I $
_ (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:
Total unincludable assets $
include on Section Ii, Line D-3 on Schedule L
111• TOTAL (Also enter on Section 11, Line D-4 on Schedule L) $
(If more space is needed, attach additional 8'/s x 11 sheets.
RED/-1647 EX + (g.Op)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
HELEN G. DOBRINOFF 21 10 0964
This Schedule is appropriate onty 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 RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
~.
2.
3.
4.
5.
II. For decedents dvinq on or after July 1. 1994. i f a surviving sDOUSe exercised or intend s to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
^ Unlimited right of withdrawal ^ Limited right of withdrawal
III.
Expianation 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 include as part of total shown on Line 13 of Cover Sheet} ...... $
3. Value of line 1 passing to spouse at appropriate tax rate
Check One ^ 6°r6, ^ 3%, ^ 0°~ ................ $
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One ^ 6%, ^ 4.5% ...................... $
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12°~)
{also include as part of total shown on Line17 of Cover Sheet) ...... $
6. Value of line 1 taxable at collateral rate (15°x)
(also include as part of total shown on Line 18 of Cover Sheet} ...... $
7. Total value of Future Interest {sum of Lines 2 thru 6 must equal Line 1) ..................... $
(If more space is needed, insert
SCHEDULE M
FUTURE INTEREST COMPROMISE
sheets of the same size)
REV-16a8Ex (11-99)(I) SCHEDULE N
' SPOUSAL POVERTY CREDIT
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX DMSION (AVAILABLE FOR DATES OF DEATH 01/01!92 to 12!31/941
ESTATE OF FILE NUMBER
HE_LEN_G._DOBRINOFF_ __ _ 21 10 0964
This schedule must be completed and filed ff you checked the spousal poveRy credit box on the cover sheet.
1. Taxable Assets total from line 8 (cover sheet) ...................................................................................... 1
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 a. x~
6. SUBTOTAL (Lines 6a, b, c, d) ..............................................................................................................
7. Total Gross Assets (Add lines 1 thru 6) ............................................................................................... 7.
8. Total Actual Liabilities ............................................................................................................................ 8.
9. Net Value of Estate (Subtract line 8 from line 7) ................................................................................... 9•
1f line 9 is greater than 5200,000 -STOP. The estate is not eligible to daim the credit. If not, continue to Part u.
Income: 1. TAX YEAR: 19 2. TAX YEAR: 1
a. Spouse ............................. 1a. 2a.
Decedent .........................
b 1 b. 2b.
.
c. Joint ................................. 1c. 2c.
d. Tax Exempt Income ......... 1d. 2d.
e. Other Income not
listed above .....................
1 e.
2e.
f. Totai ................................. I 1 f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(1f) + (2f)
+ (3f)
0.00
0.00
AX YEAR: 19
(+3)
4b. Average Joint Exemption Income ...................................................................................:........................... °=
It dne 4(b) is greater then 540,000 -STOP. The estate Is not eligible to claim the credit. /f not continue to Part Ill.
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .....................................
2. Multiply by credit percentage (see instructions) ....................................................................................
3. This. is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet ..............................................................
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate ........................................................................................................................
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet ..........
•
1.
2.
3.
4.
5.
REV-1849 EX + (8-98)
COMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
SCHEDULE O
ELECTION UNDER SEC. 9113(A)
(SPOUSAL DISTRIBUTIONS)
ESTATE OF FILE
HELEN G. DOBRINOFF 21 10 0964
Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance &fstate Tax Act
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital residual A B By-pass Unified Credit etc )
If a trust or similar arrangement meets the regwrements of Section 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 specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim-
ilarproperty treated as a taxable transfer in this estate. If Tess 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
survivingspouse under a Section 9113 (A) trust or similar arrangement.
Description Value
Part A Total $
Part B: Enter the descri tion and value of all interests included in Part A for which the Section 91 13 A election to tax is bein made.
Description Value
Part B Total $
(If more space is needed, insert additional sheets of the same size)
l~EU-'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 1994
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:
i otal Balance Due on January 17, 1996:
penalty: