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HomeMy WebLinkAbout03-10-111505610101 .. '-'~' REV-1500 ex `O1.1°' o PA Department of Revenue pennsylvarria Bureau of Individual Taxes Eo.a.~E~.~FpINHERITANCE TAX RETURN PO BOX 280601 Harrisburg. PA 17128-0601 RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number _~.,..., ; t_.. ~.- ~, Spouse's Last Name Suffix ,-~.•+ ..~.,~ S se's Social Security Number Date of Birth MMDDYYYY Decedent's First Name MI ~~. t '~ ~,,~ ~,~~ Spouse's First Name MI ~ I. you THIS RETURN MUST BE FILED IN DUPLICATE WITH THE IT~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW i 1. Original Retum O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 8. 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 T0: Name Daytime Telephone Number REGI~~F WILLS ~iCE ONLY !_r.~ ~ C7 :~ ~. 7 First line of address r_ ~ m -- `.,~ cn ~ ~ _' - Second line of address r] C -r~ -~ T~ c J;' -cv ~ tom', `~- r ' ~ -` - ~- ~~ ' `~ D DATE FILE~"' ~ City or Post Office State ZIP Code . L ~ ~ ~~~ mer - . -~ .~~r-,n.:. ~ ~ ~~°c.~ ~ y s ..~ .. . . , Correspondent's e-mail address: Under penaRies of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Dedaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN OF P ON PONSIB FOR FILING RETURN DATE AUUKtJ e , ,' ~ ~ D/ /'t 1 ~s rv~ J~4_ /4 7 SIGNATURE OF REPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J J REV-1500 EX Decedent's Name: 1. Real Estate (Schedule A) ............................................. 1 Decedent's Social Security Number .~. >. ~ 2 ~ ~ t 2. Stocks and Bonds (Schedule B) 9w ~_~. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~ u.. a 4. Mort a es and Notes Receivable Schedule D 4 ~ ~ ~ i 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. t ~ p F ~ '' 6. 7 Jointly Owned Property (Schedule F) O Separate Billing Requested .. Miscellaneous Non-Probate Property Transfers 8 Vi I t ..... 6. ~ _ ~ ~ ~ ~~ ~ ~ r ''*;.~ ~`~ . ~ er- vos n (Schedule G) O Separate Billing Requested... ..... 7. _ t ~ (~ 8. Total Gross Assets (total Lines 1 through 7) ........................ ..... 8. ~ a,.. ,41 L~ _ 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. ~I 4 f ! ! ~•~ Y. . 0. ebts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) ........ ..... 10. ' 4._y ~~~ .. - ' ~, ~;~ `. ~ r ~ ~ ~~ .~. .~ ~ 11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. ~ ~) ~: Z 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ ~ ~ ~ 7 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. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or . . transfers under ec. ~ ~ - ~ ~' ~ 15. 16. Amount of Line 14 taxable '"~ °° ~ ~~"'~ "_ ~~' `~ t~ '""'' ~`~ ~F'' at lineal rate X .0 ~ ~ ) I ~ 16. 17. Amount of Line 14 taxable ~ '''~ at sibling rate X .12 t ;~ ~ 17. 18. Amount of Line 14 taxable `~ ~` at collateral rate X .15 18. c s.~,~.,.~ ~ m 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610105 150561.0105 1505610105 'sZ I[ t.--~ P~ ,,., ^ ~' k s:,C "~~; O REV-1500 EX Page 3 File Number 11..weelnnf~~ ~`nwtn~o+p Oflfll'P_CS_ YG4riM~i~ ~a .~ vv"".rr...... ~ .~-~-- ---- DECED TS NAME STREET ADDRESS o.~r1 ~yR. !~ ~cy~ _ -- CITY --- S TE ZIP ~ S.Bvr< ~- - (70 I Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments ~33. ~ A. Prior Payments •. B. Discount Total Credits (A + B ) 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) 50l ~~. (~-,z (2) 5~~3, o ~ (3) (4) 5. if Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ y i 6 ~ 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 .................................................................................................................... ? f ...... ^ ^ p~~ ................................................................ its or care d. receive the promise for life of either payments, bene ...... ya 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? ........................................................................................................ h? ...... ^ ....... 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 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)]. 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-1502 EX+ (6-96) SCFIE®ULE ~ COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. (If more space is needed, insert additional sheets of the same size) REV•15RiE%• (tom SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STACKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT EST E OF ~~ (( C ,, FILE NUMBER Q 4 (' L ~6 20l'~ly ~ '+~s 2LZG~ N ~ /T ~ ~ ~ ] ~' Q 7 ~t'J All property jointly-owned with right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM NUMBER DESCRIPTION OF DEATH '~ ~ ~ ~ ~ ~~ t~ s ~.. 1 S~o c IBS ~ TOTAL (Also enter on line 2, Recapitulation) I ; /Fj ,~~ d ~ ... _ -- _-- -- ---~_~ :._...a ..d.IN~..n.il o6nnM of 4hc c~mo ci~w1 REV•1508 IX • (137) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY oeein[uT nFCGnGNT _. ESTA E OF FILE NUMBER ~ts~-I-I~ y L' S6-~zr6 N©~..~ vtt O 9- O °J~ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-0wned with the right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM OF DEATH NUMBER DESCRIPTION 1. ~ b1M~t12S S, no S', o ~ 2. I M t~ ~~-S Co 3S, ~z ~~ 2 Sf ~'C ~ c.~ ~z~~ti~ /4cc.~ ~ ~ S. y z TOTAL (Also enter on line 5, Recapitulation) I a ~7 ''/ ~ y Z (If more space is needed, Insert addltlonal sheets of the same size) REV-1511 EX+ (12-99) . SCHEDULE H .COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTA E OF FILE NUMBER b Qo~.,/ ~ ~R S6-.v ~ ~ 'r 021 r7 S - O 9 4tS Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: L ~N/~1i4 o~v ~ ~/OW eIZ- ~Zcu.~fi ~v 1. ~4~2ot~ Ntw s 3s~so, °~ ~ + ~~ 3 y ~.~~ ~OUfLN~4~ ~S~ ~ g. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees ~~ ~ ~ 00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant i~1R2.~ ~1 ~~s-2t ~~a I~ ~ ~ ©~ °c Street{{A~~ddress n~7 yOQIrC 7=dh~ City IJ r ~~ Z B U A-L~r ~1~ (7 6 l S State Zip Relationship of Claimant to Decedent ~ a 4. Probate Fees OCR .`~ ~~ 5. Accountant's Fees g. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ ~ ~~ / 4'S, yy (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 SCNEDI~LE 1 DEBTS Of DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTAT€ OF FILE NUMBER DoR~~ C.. ~~Gie.s6-n~a~s o~ /D ~i -~g~S~" 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 wS ~~S ,~~,~3 t~+4 M~dc~ 7'w~ ,scw cxr ~T~ ~ ~ ~~ 7 ~ 30 G~ r~d~ ~(v~ G~asS ~lf~i .~tiS ~Z(P- ~ P TOTAL (Also enter on line 10, Recapitulation) $ I ~~ ~,~, 73 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTAT OF dt ~' . s 6-R .~lrv d ~+ ~- NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. I T~~ _7 L . ~fZ (~~~ ~~ FILE NUMBER 021 O ~' ' O ~S ~S~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE .So ~•- I !DD 0l0 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 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. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 ~/ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size}