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HomeMy WebLinkAbout05-13-111505610101 ~ REV-1500 Ex ~°1.1°' '!~' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania DEPARTMENT OF REVENUE County Code Year File Number Bureau of IndfviduatTaxes PO 60X28060 INHERITANCE TAX RETURN ~ ~ C ~ ~ 7 ~3 Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~ ~, ~o ~~g~ b ~j2Z~o (o bZ L~ L ~y ~. Decedent's Last Name Suffix Decedents First Name MI ~v~~d "P ~ S ~~~ A L ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Narne MI G t~ T ~ ~ d `~j ~ -~ ~~ ,~ ~ ~ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE .~ y I (r, 0 ~ 1 1 ~ REGISTER OF' WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Return O 2. Supplemental Return CD 3. Remainder Return (date of death O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) C~ 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes C7 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 TO: Name Daytime Telephone Number ~~ ~~~N~ G~z-~© ~ ~ ~ ~~~ ~ ~~ $ First line of address l ~.5 IL.Q~tL.:~~`~ L~N~. Second line of address City or Post Office State ZIP Code Correspondent's a-mail address: ~~ loo ~~ "r-t -~ _, =, ___, rl -;1 Under penalties of 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. SIGN\ATURE OF PERSON ~SPON BLE FOR F RETURN ~ DAT J ~ J ~ ~j ~ _ ADDRESS ~ ~ ~ ~ ~~ ~ ~~~ ~ ~ _I Z'S L~ ~ r { ~ c c r-- ~ ~. i ~ -c - SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 ~~ REV-1500 EX Decedent's Name: RECAPITULATION 1505610105 Decedent's Social Security Number 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 and Notes Receivable (Schedule D) ........................... 4. ~ ~"'-'~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ `7 S s L 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested........ 7. , 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ``.1 ~ ~ ~ ; ~ '~ 9. Funeral Expenses and Administrative Costs (S~hedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) .............. 10. , ~" 11. Total Deductions (total Lines 9 and 10) ................................. 11. .~. ,, (~ 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. :~. ~ ~ 3a, ~..'... ~ ~ , Z S 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. ~ i ~ 'S ~, Z ~ TAX CALCULATION -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 a . , _ ,~ ` , . : ,,, ~k ,,~:=1 ~ -~, , at lineal rate X .0 __ 16. 17. Amount of Line 14 taxable _ , = ~ .. _f, .~~ ~ a~~ Y ,.;~ ~~,. r~~~- .4~'~:> at sibling rate X .12 ~, 17. ~ , 18. Amount of Line 14 taxable ~ . ~ , .r;_ .~~ .,. ~..:~ ~ ~ .~~ ~~?u... ~ . ~ f.~. ~ -r .~~~, at collateral rate X .15 • 18. ~. 19. TAX DUE ......................................................... 19. .3y, ~ ~L" 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM ENT p Side 2 1505610105 1505610105 J REV ~ Si,~ tX Page 3 na~pdpnt'c rmm~lpte Address: File Number DECEDENT'S NAME STREET ADDR~ ~ 2 5--- ~ g w ~~~ c-~. ~. r- - --- -- - - -- CITY 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. (1) Total Credits (A + B) (2) (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. Yirv w ~ ~ !.. .. 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 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? .................................................................................................................. ...... ^ ~' IF THE ANSWER TO ANY OF THyE ABOVE QUESTIONS 1S YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. t r - 1. Y ., .fit ,~~ ,< is i q ~, fi-.'~I ~ ? ~ i..4 ~ ~'~ ~' ~.'» ~ ,~.~` ~'Sa ' ° 'q ~~`,:Ct* b' ~~', ~r! ~.~, ~ .. ~'~~ ^ " :` t-s r, x~~'~ ~ ?~z ~. ~~ sz .,:s~'=`~k`. _ '~f=~~,~,Ci`.'.~ ~d :~c'F, a~~'4 ?.:rs- :t',.._» .. tr~'"~a"'~. ..r-~__-... .. .'S- -~--- .~ _=L~`Y7. ... :~ .. _.. _. *E~.. --_ s - Fordates 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 statu#ory 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 ar adoption. 'REV-1508 EX+ (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 ,. d d ~ c ~ ~ P~~. ~e ~'enk~, Sow ~e e,z re ~ Vlh,~~. ~$~~g 5~•2~t 5~~~--5 s ~E ZCo~S~ 2. 4~Z.., ~e ~ 1~1D n 2 ~ ~~ rLt e -~- S~ v ~ --~ TOTAL (Also enter on line 5, Recapitulation) I $ ~, , ~ 5 ` Z S (If more space is needed, insert additional sheets of the same size)