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HomeMy WebLinkAbout04-21-11 (2)1,5056051,047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue -- Bureau of Individual Taxes r; :~ - County Code Year t=ile Number PO BOX 280601 INHERITANCE TAX RETURN ~ ~ Harrisburg, PA 17128-0601 -4 - ~~ RESIDENT DECEDENT ~" ~ ~ ~' ~ ~ ~ -~ ENTER DECEDENT INFORMATION BELOW -- Social Security Number Date of Death Date of Birth 20~ a3 ~1z7 1 t~3~,y2ot 0 ~~ ~7/~~~ Decedent's Last Name Suffix Decedent's First Name MI ~~TERs L ~na~ ,~ (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 ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number G~ ~1? r ~ ~ ~-~~"~ X2.5 ~Z'~ ~ 1 ~ ~--~ y ~6 ~ , Firm Name (If AnnlicahlPl THIS RETURN MUST BE FILED IN DUPLICATE WITH TNIE REGISTER OF WILLS O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate T~~: RReturn Required __ 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) First line of address 3e3~ ~%~~ ~ ~~ c ~ ~~L ~o~-.D Second line of address City or Post Office 1~l~ ~~e j S ~ v ,~ G- State r° ~ REGISTER C~F~VILI_:i USE ONLY ,---~ ,~~.:r :~7 ~~, _.A._ .. ,. ...... l.J w.... ._>> , _~ -,, C~ ~_ ._,~ ;~!__ _ _. ~fE~IILED ~-..~ ZIP Code ~ f ~ ~ ! ~-. Correspondent's e-mail address: ~S~Lo~ n~~ ~ D~ C'AST ~ ~~/~ .:a_1 :..7 _:~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge an it is true, correct and complete. Declaration of preparer other than the personal representative based on all information of which preparer hias any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ~ DATE ADDRESS ~-~-~~ 3 0 3G ~~s ~,:~g c:,e ~~ L ~ NQ p~I / ?/~2_ _~ -.zo ~/ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE= ADDRESS w -- -- PLEASE USE ORIGINAL FORM ONLY Side 1 1,5056051047 1505605104' J J 15056052048 REV-1500 EX Decedent's Social Security Number a o ~ ~ 3 8~7 / Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. • 2. Stocks and Bonds (Schedule B) ....................................... 2 • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. ' ~~ p~y•o ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. • 8. Total Gross Assets (total Lines 1-7) .................................... 8. ~ a ~' 7 ! • 0 d 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. • 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. • 11. Total Deductions (total Lines 9 & 10) ................................... 11. ~ • ~ ~ 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12 / ~ V 7 ~• ~ 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which D an election to tax has not been made (Schedule J) ........................ 13. • ~n AI n4 \/~I~~n Cuhiartf to Tax (I ine 12 minus Line 13) ........................ 14. 6 d ~ ,( • TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable ~ ~ ~ Y ~ 1 ~ ~ ~ • v 16 , • at lineal rate X .0 mss"' . 17 Amount of Line 14 taxable . at sibling rate X .12 • 17. • 18. Amount of Line 14 taxable ' 18 • at collateral rate X .15 . 8© • ~ ~ 19. ................................ TAX DUE ................... . .....19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 15056052048 15056052048 REV-' i00 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME L / /~ a~ STREET ADDRESS `p00 tv CITY ~ p~~~r~5 ©l Tai Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) __ l X03 Total Credits (A + B + C) (2) Total InterestlPenalty (D + E) (3) 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. (4) 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 + 5A. This is the BALANCE DUE. d (5) l ~C 3 (5B) (5A) Make Check Payable to: REGISTER OF WILLS, AGENT STATE ZIP ~~O 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? ........................................................................................................ ...... ^ 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 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 sur~~iving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)J. 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 twenty-one 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 zero (0) percent [72 P.S. §9116(x)(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.~~) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(x)(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(x)(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, ~ M~S<r. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ~. ~ rr aka ,~ 1° ~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 ~ 7- ,8a-~r.~ / ~~d,o~y~ ~~ ~~S bui U~~iG~ /Ilv,r-~t U S /`~ /~ d~ TOTAL (Also enter on line 5, Recapitulatior~~ $ ~D 0 7 ~ Oa (If more space is needed, insert additional sheets of the same size)