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Home My WebLink About02-23-11 505610101 REV-1500 E,tt°'-'°' m' l M OFFICIAL USE ONLY PA Department of Revenue Ptmnsy va a Bureau of Individual Taxes PO BOX 28o6os Harrtsbura. PA s7i28-o6oi o..M*~M«.~~x~E INHERITANCE TAX RETURN RESIDENT DECEDENT Caunty Code Year ~ ® File Number ~ / - ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death '' 8 i Decedent's Last Name (If Applicable) Enter Surviving Spouae's Information Below Spouse's Last Name A Spouse's Social Security Number MMDDYYYY Date of Birth MMDDYYYY 3 l9 Suffix Dec~ed-ent~s First Name MI ®' `~ `'' U Suffix Spouse's First Name ~~ MI ~ ' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~- 8 - YIU~g 0 ~ 5 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW p 1. Original Return O 2. Supplemental Retum O 3. Remainder Retum (date of death prior to 12-132) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum 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) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Teleph Number ~ ~ ~ 9 U~ First line of address ~ ~ n -~ c -,, ~ :; " ~ a r Second line of address ~~ `~ r ~•` City or Post Office State ZIP-Code DATE FILED s `®C ~~.~ Correspondent's a-mail address: Under penalties of perjury, I dedare that I have examined this ietGm, including a it is We, Ca d complete. Dedaretion of preparer other than the personal SIGNATU OF RESPON TURN ADDRESS ~- z/ (~ l E- ~il~ ~l/P s'1 i~ P /. SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~/ 0 DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 chedules and statements, and to the best of my knowledge and belief, is based on all information of which preparer has any knowledge. DATE z „ 1505610101 REV-1500 EX Decedent's Name: Decedent's Soda! Security Number RECAPRULATION rw,q~.uur re.w ac y 1. Real Estate (Schedule A) ............................................. 1. ~ ~ 2. Stocks and Bonds (Sdredule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Sdredule D) ....:...................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Properly{Schedule F) O Separate Billing Requested ....... 6. . 7. Infer-Vrvos Transfers & Miscellaneous Non-Prate Property (Schedule G) O Separate BNling Requested........ 7. 8. Total (cross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Sdredule I) .............. 10. 11. Iota! Deductlons (total Lines 9 and 10) ................................. 11. 12. Net Valve of Estate (Lure 8 minus Line 11) .............................. 12. 13. Charitable and Governmental 8equests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. ~ y ~ ~ 14. Nat Valve Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at tire spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X .0 _ 17. Amount of Line 14 l~fabie at slMing rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTgIti A REFUND OF AN OVERPAYMENT Side 2 L 1505610105 1505610105 1505610105 O 3 Decedent's Complete Address: Fik Humber DECEDENTS NAME ~! /~~ {~/~ (1 ~Y u~ / '` STREETADDRESS Zed CfTY ~ ST ZIP 1 U ~ Tax Payments and Credits: 1. Tax Due (Page 2, Lore t9) 2. CredilslPaymenls A. Prior Payments B. Discount Trial Credits { A + B) {2) 3. Interest {3) 4. If Lme 2 is greater than line 1 + ~ 3, enter the rrittererlce. This ~ the 01fERPAYMEWT. FiN in oval an Pape 2, LGw 20 tD raqusst a refund. {4) 5. ff Line 1 + We 3 is greater than Line 2, enter the difference. Th's is the TAX DUE {5) Make check payable to: REGISTER OF WILLS, AGENT. ~f90 `~~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :............................................................................. Yes ............. ^ No ~/ b. retain the right to designate who shall use the property transferred or its incxxne : ............................... ............. ^ ~ "p c. retain a reversionary interest; or ............................................................................................................. ............. ^ ,Q,~/ d. receive the promLse for Fite of either paymerds, benefits or care? ......................................................... ............. ^ L~' 2. H death ocalned after Dec. 12, 1982, did decedent transfer property within one year of death ~, / without receiving adequate cansideration? ................................................................................................. ............. ^ L~ 3. Did decedent own an in trust for" or payable-upon~death bank account or security at tus or h~ death? . ............. ^ [+~~ 4. Did decedent own an individual retirement accamt, annuity w other non-probate properly, which contains a benefiaary designation? ........................................................................................................... ............. ^ ^ ' 16J~ IF THE ANSYYER TO ANY OF THE ABOVE QUESTIONS 15 YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 survivirg .spouse is 3 percertt j72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or afar Jan. 1, 1995, the tax rate imposed on the net value of transfers fd or for the use of the surviving spouse is 0 percent ]72 P.S. §9116 (a) (1.1) (ii)J. The statute does r>~ exempt a transfer to a survivingspouse from tax, and the statutory requirements for disclosure of assets and ffiing a tax return ~e s1iN applicable ever) 'rf the surviving spouse is the onty berleficlary. 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 of age or younger at death to w for the use of a natural parent, an adoptive parent or a stepparent of the cluid is 0 percent (72 P.S. §911t3(a)(1.2)]. • The tax rate imposed on the net value of trarlsters to or for the use of the decedents lineal beneficlaries 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 deosdent's siblings is 12 percent ]72 P.S. §9116(aj(1.3)]. Asibling is defined, under Secliorl 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-05o`EX.It-071 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY FILE NUMBER Indude the prooaeds of litigation and the date the proceeds were received by the estate. All properly jointyowned vAth tha right of survivorship must be discbsed on SeheduN F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~1 ~~ ~~ ` \~~ b c,~x _ ~ \ ~~ ~ ~ ti, ~ X ~~ ~ ~5 ~ ~a ~ ~~ ~~ ~ J~ ~~ ~~ ~~` ~\~ o` . TOTAL (Also enter on line 5, Recapitulation) I S (If more space is needed, insert additional sheets of the scene size) '~~eeoc.ngn Cq~MpNWEALTH OFPENNSrWMNA INHERITANCE TAX RETURN ESTATE FILE Include the pmoeeds of Ytigation and the dale the pnxsieds wets receNed try the estate. All property jointly~owned witlt the right of wivivorship nwet be dtselosed on SCheduk F. VALUE AT DATE ITEM OF DEATH NUMBER DESCRIPTION 1 ~~w ~S F~~ SCHEDULE E CASH, BANK DEPOSITS, S MISC. PERSONAL PROPERTY ~j ~~ ~ ~~ o~ r~V~ ~~~ ~~ ~~ a o-' ~ ~~ ~ J~ ~~ Y ~~ `0~' ~~~~ J (If mere space is needed, . ~'1 ~; TOTAL (Also enter on Tine 5, Recapitulation) I i add'dioral sheets d the sine sine)