HomeMy WebLinkAbout05-03-11,~
REGISTER OF WILLS
150561,01,01
REV-1500 Ex X01.1°'
OFFICIAL USE ONLY'
PA Department of Revenue Pennsylvania ---
Bureau of Individual Taxes oEPAR.ME"T OFRE~E"°E County Code Year File Number
PO Box 28o6oi INHERITANCE TAX RETURN ,
Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ~ ~ ~ ~-- V ~~ ~'
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Name Suffix Decedent's First Name MI
~ ~A I~ tV ~ 1~ ~ ft ~ G- ~ ~ I f ~..
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
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)
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
O 11. Election to t<3x under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
First line of address
Second line of address
City or Post Office State
~~~~z/~Qt`T~~iawN P~
Correspondent's a-mail address:
ZIP Code
REGISTER. OF VVILLS USE ONLY
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
SIGNATURE OF PERSON RESPONSIBL FOR FILING RETURN -~-DATE
s=a-i~
under penalties or perjury, i declare 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 complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
HUUKtSJ - --~~~~...~.-.-...,.~..-~.-.~-
~. PLEASE USE ORIGINAL FORM ONLY _~~~..'~~--~~
Side 1
1505610101 1,50561011D1,
y
T
~ I
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: _ ~ ~ ~ ~ ~ ~ ~ h
RECAPITULATION _._._ (~' ~ ;
1. Real Estate (Schedule A) ............................................. 1. v •
2. Stocks and Bonds (Schedule B) .................................. ..... 2. ~ + O
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~~ ~ ("i
• V
4. Mortgages and Notes Receivable (Schedule D) ...................... ..... 4. (~) ~ (~}
s j )
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... .... 5 ~ ~ ~ ! I ~ r
~
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ...
7
I
t .... 6. ~ «
~ ('-,
.
n
er-Vivos Transfers & Miscellaneous Non-Probate Property v
(Schedule G) p Separate Billing Requested.... .... 7. ~«
8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. -- I_
~ • ~ ~~
9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. ~ "l O ~ ~ ~ f
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. --,
11. Total Deductions (total Lines 9 and 10) ............................. .... 11. (~
I ~ ~ ~ ~ r~
'1
12. Net Value of Estate (Line 8 minus Line 11
..........................
13
Ch
it
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....12. `-t t~ ~ / ~ i
.
ar
a
e and Governmental Bequests/Sec 9113 Trusts for which cp I
an election to tax has not been made (Schedule J) .................... .... 13. U ~ ,l /~
v V V
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14.
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6 C~ . ~
TAX CALCULATION -SEE INSTR .
UCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15.
16. Amount of Line 14 taxable «
at lineal rate X .0 ~~ ~ ~ ~ ~ ~ , ~ I
17
A 16. ~'
~ ~ (~ ~j'
~ ` "
.
mount of Line 14 taxable ~ O
at sibling rate X .12 a 17.
18. Amount of Line 14 taxable `
at collateral rate X .15 • 18.
19. TAX DUE ...................................................... i ~j
... 19. { 0 c~.' "I • `1 ' g
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505610105
Side 2
1505610105
O
RED/-1500 EX~ Page 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME
. ,
-- -_
STREET ADDRESS - - - ---- - -- -
~ --
-_ - -_
cITY _- -_ _-__-__
Y^ -
~n~lc
---- _
-_---
STATE ~ ZIP -- ------ - - ----
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. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B) (2) ____ ~j , ~~ o
(3> ---- C~ ~ ~-->C.~
(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 N,~
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 ............................................................................
.............................................. ^ C~~
d. receive the promise for life 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? ..................................
...................................................................................... ^ C~
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 survivin souse is
3 percent [72 P.S. §9116 (a) (1.1) (i)]. 9 P
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 pE;rcent, 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-1508 EX + (1-97)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RESIDENT DECEDENT RN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
~< er im, ~ ~, 1~Ja~rn~r fir,
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
NUMBER VALUE AT DATE
DESCRIPTION OF DEATH
1.
~ ~ ~~ ~~~
etc ~~~ ~ ~A~ i 70 ~.5
~ hoc.. <<t r~ c~ A~.:+
~ I~3~, ~v
~a.~ ~ nc ~ pia L ~3~nK
L=..~l~IC7~ ~~ 170a~
5«~~n~~
~(j~-O`-f70-- ~~ 71
~' ~f ~{ 17~ 30
TOTAL (Also enter on line 5, Recapitulation) I $ ~ 5 (,~,
(If more space is needed, Insert additional sheets of the same size) y `~ t
REV-1511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
1.
~" t1y C~ ~ ~ ~. `~ ~ ~~~ SS ~' (~~, ~ ~" c.t n ~ r~~.~ rl~ ~ ~'t~% ~r'1C
3a~ ~-l~,c vn rn ~ ( ~4 vc~ Inc,~c..z..
Lc m~~ n~ ~ ~~} ~ ~ U u
1'u~1`(~a PIC*,n ,,nClvc~e~ ~~~r+ic,~~~~ evyrbc~l~,~~7rj~
i' (il ~ S ~ G ~ ,~". G'lT' ~ iJY1 ~ C. ~C~~thQ ~ ~ -~+ 1 ti :1r.^'~-rte 5~ ~.2 ~p€ ~i"e~ t' C~ ~ t~ ~+
5 2 t v i c, ~ < o st of .b~.~ ~'ir~M .1
~ lcc ~ ~ ~~ I I C ~ ~'~'''~~"y~r.J' - ~ ~'~' r1i,~G~ ,~' ~, ~-c1v ~
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: (lf decedent`s address is not the same as claimant's, attach explanation)
Claimant
Street Address
City ------ - - _ _ _ _ _ -
- _ State -Zip _ _
--
Relationship of Claimant to Decedent
4. Probate Fees ~ ~ 1- -~
F
5• Accountant's Fees .J
6. Tax Return Preparer's Fees
7.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
_ AMOUNT
~~~9, 76
~-~~ ~ ~U
~~~~L)
5~ ~ Q O
TOTAL (Also enter on line 9, Recapitulation) I $ L~ 7 (~
(If more space is needed, insert additional sheets of the same size)
ESTATE OF
FILE NUMBER
ITEM Report debts incurred by the decedent prior to death which remained unpaid as of the d ate of death, including unreimbursed medical expenses.
NUMBER DESCRIPTION VALUE AT DATE
~ _ OF DEATH
~S ~ ~ N wu.s mc~ ~ 2a .
.~,11c~~ro~~~
PA 1~~0~
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~~ ~ ~ rQ I ~i I- L.C~~.ti ~ ..~"E~~ Php ~ ~ S~-~1!)C~ ~~ r ~ 7
5 ~ f
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
TOTAL (Also enter on line 10, Recapitulation) $ I ~~,1l~, Q~
(If more space is needed, insert additional sheets of the same size) ____
REV-1513 EX+ (9-00)
aa.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
r AT~Tl~• w
SCHEDULE J
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
~o~c~~~ mot.
~. Lorrct~n~. i~~uJ~t~
~3, N~~~hciel ~ ~ ~1~~ne r
~, ~ t~. r ~ -D . "~~ r r~ ~r
~~ ~ ~P ~ i~`y -2~
~ L ~P1 i t S ~J t.C (-G~ , '~ ~t i1 C~ 5 ij
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
S d ~1
5 f,,~1 ~.$ ~~ v2C) ~ : ~3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON RE\/-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size) ~ ~ ~~