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HomeMy WebLinkAbout07-19-11 1505610101 REV-1500 ex ~°1.1°' ' OFFICIAL USE ONLY enns lvania PA Department of Revenue PEP.A ME~Y ~ ~~ p County Code Year File Number Bureau of Individual Taxes INHE RITANCE TAX RETURN ~ t l C PO BOX 28o6oi Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ ~ ~ ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY (S3 rD;ao2sr~ b~o2~~ 0 1 ~ 08 ~ ~ ! ~~a Decedents Last Name Suffx Decedent's First Name MI Sw~I~A 2 ~ ~ ~~~ANO fQ /7 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI S~~r4~,~~ ~tiA~c~s ~. Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE l tj;8 S'c~ g 3 ' `~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate 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) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 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 G~AQL~s ~ Sw~.~Grv 2 T' 7 / ? ~~ ~ s"6SS' First line of address /~ G Lp U S~ Second line of address City or Post Office ~ ~w r/ jLL~ Correspondent's a-mail address: /~ ~. State 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. SIGNATU PERSON~j PON FI G RETL~2N DATE w /I~SA ~-ifi~ _ ~ 7~-/~~ 7s1i / ADDKE55 G ~ ) / ~ GELD y S~ Nf?,`t, ve SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 REGIST~ OF WILLS U';E' ONLY ~ ~- -m- Q ~~ ~ C i > n, _ . ' l~n `"~ m r--_ .i ~ . .f' ~~~ ~ ~~ ' :) C - ~ DATE FILED ,n ZIP Code ~ ~~ ? d- Y 1505610101 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: ~ 8 3 ~ © . ~ 2 ~~ RECAPITULATION v 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. 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. x 0 C1 ~ P~ O .~ _ "b o :~ ~.; ~ ~~ 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ r~ 9. Funeral Expenses and Administrative Costs (Schedule H) ...... ........... .. 9. ~ . ._~. ._m ~-.,_...- r d ~~ ~ ~ ~1 .. -..rp a. ~. •.f;- .i~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) . ........... .. 10. ~ { F b ;O , O F 11. Total Deductions (total Lines 9 and 10) .................... ........... .. 11. ~ '7C ~ l ~"~"© 'M -fi, ~ z 12. Net Value of Estate (Line 8 minus Line 11) ................. ........... .. 12. i D 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which - ~ = -~+ '' °t" • ~ ~ > 5~.: ~~ ?, an election to tax has not been made (Schedule J) ........... ........... .. 13. - s~ 1J r ° .,:`~_ 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 Sec. 9116 d-...~ -~ - -•: ~~, r _.~. _ ,.,,. ,t . (a)(1.2) X .0_ i d d 15 ~ 16. Amount of Line 14 taxable ~• - ' F. ~, ~ r~ ~~, .,- s -'~~ ~~r ,~_ ~ at lineal rate X .0 _ ~ ~ . 16. { c ~ ,D ~b ~ 17. Amount of Lfne 14 taxable ~ ~ ~ ~"'~ ~ ~'~ ~ ~ ~ -~' ~ ~~'' ~ ~~~'~ ~ at sibling rate X .12 ~~ ;(~ 17 ° ~ ~ i~ ~~ 18. Amount of Line 14 taxable i ~.~ p ^ ~~: ~~ °rx. m. -~ ~,_,;;,: r ~ ~~s.~ wti~~,~ ~ l ,ri at collateral rate X .15 +~?~ ~ ~ 18 ~ ~ ~ a ~~' 19. TAX DUE ............................................ ........... ..19.' ~ ! ~ " ~~;: 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 O REV-t.,v~ ~~ rage 3 Decedent's Complete Address: UCIiCV LIV i v iv STREET ADDRESS ~~ ~~ CITY ~ q /VP wri Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments --- B. Discount ZIP l/ l ~~ 7 , (1) ~^ ~ ~- -O ~- Total Credits (A + B) (2) 3. Interest (3) ~~~ ~'~ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 4 ~~ ~~ 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. (5) ~ 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: YesN~o/ a. retain the use or income of the property transferred :.......................................................................................... L-J L'J 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 r-~~ contains a beneficiary designation? ........................................................................................................................ L!f ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. h. ~b ._r ~ _ ~..C~- 1, f. i, _ - .' _ 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)]. Far 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 appligbie 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 an 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}]. 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. File Number /. -F- --- ~TATE REV-1510 EX+(L97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ~~~~ ~__ _ / %~ c~u~~~st-~.o,~ i cif //D °-Dlo' ~n This schedule must be completed and filed if the answer to any of questiorlsi through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE // ~/ rr ~ r ~7 ' S~. vim/ U /le TOTAL (Also enter on line 7, Recapitulation) I $ -^-' D -~------- (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCI~IEDULE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts•of dece must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1 FUNERAL EXPENSES: ~`j/'~~ ~~~~~ ~~~ G G (~iC~ v L ,.~~* ~po2C~. 7d IS'' w ~3 ~~ 5,~,~~.~s Jd~ e. B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip --__ _ ._ _ 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent _ __ __ _ _ ____ 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip TOTAL (Also enter on line 9, Recapitulation) I $ ~Q~Z~ ~ ~~ (If more space is needed, insert additional sheets of the same size)