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HomeMy WebLinkAbout07-21-11 (2)1505610105 REV-1500 EX (o2-ii) (FI) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number DFPARIHENT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN hh ~~ 1 Po Box 28o6oi RESIDENT DECEDENT oU' t ~ d ~~~ Harrisburg, PA x'7128-o6oi ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 9 Decedent's Las't'Name Suffix Deceden`t's! First Name Nll (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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW i 1. Original Return 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 Return Required death after 12-12-82) 4 6. 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytirne Telephone Number GI~R A s~ ~ T~ ~'~' ~"~~Y-3~-b~1 REGISTER OF WILLS USE ONLY.; ~_ :~:~: ~ c ;~ w DATE ED t=~ ~ .. '~_? ~"~ r-r-~ C7 First Line of Address Second Line of Address City or Post C)ffice i~/ ~ ~l ~ u ~ ~ ~ n ,C ~- N ~ State ~~ ZIP Code l ~ o~0~~,~3~`~ ~~~ Correspondent's a-mail address: - = ., '"~ _i...} _ ~' ~. ~ s"z"t :n 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, r ct and complete. Declaration of pre er other than the personal representative is based on alf information of which preparer has any knowledge. SIGNA OF PERSON RES ONSIBLE F FILING RN ~ ~ DAT A DDRESS r SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number 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 and Notes Receivable (Schedule D) ........................... 4. '-- 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~.~j / ~ ~, 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~ ~ G '~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. ~- - °'-"„ 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ i, ~ ~ ` r ,~ d 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ C,) ~ 3 ~ ~ ,,~ 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. ----- f 11. Total Deductions (total Lines 9 and 10) ................................. 11. ! (~'/ ~ 3 ~~ J 12. Net Value of Estate Line 8 minus Line 11 .............................. ( ) hi h 12. ~~ / qty'- aG 13. c Charitable and Governmental Bequests/Sec 9113 Trusts for w an election to tax has not been made (Schedule J) ........................ 13. --- - " '-'- 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ f ~ 7 , 0 cs TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 (a)(1.2) X .0_ . 16. Amount of Line 14 t x~le ~ ~ ~ ` ~ 0 ~ at lineal rate X .0 ~ (. 16. t ~ ~~ - 17. Amount of Line 14 taxable ~ at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19. ~ ~ ~ ~~ f 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15D5610205 1505610205 O J REV-1500 EX (Fi) Page 3 Dpcpdpnt's Comulete Address: File Number I~Q /f ,,,r a ~ ~~.~ DECEDENT NAME STREET ADDRESS CITY C -~w ~ C~' ~Jw~' STATE ~ ZIP ~~~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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) ~~'~ (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. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ye^s 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 .............................................................................................................................. ^ 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 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(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. c J 150561205 REV 1500 EX (FI) Decedents Social Security Number Decedents 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 and Notes Receivable (Schedule D) ........................... 4. "'- 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~~ ~ ~ ~ !~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~ ~ ~, ~ ~ 9 7. Inter-Vvos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. - """~- 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. /`° ~~ q ~ ~ i -° ,3 9. Funeral Expenses and Administrative Costs (Schedule H} ................... 9. f Q ~ 3 ~~, 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule 1) ............... 10. ....~ _ ~"' 11. Total Deductions (total Lines 9 and 10) ................................. 11. ! ,(9 ~ 3 ~~ ~ ~' 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. l ~ ~ ~ 4 Y (~ G 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which / - [ an election to tax has not been made (Schedule J) ........................ 13. ~ ~.._... ~ ' -'-" 14. Net 1Falue Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ ~~ 7 p O TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ - 15. Amount of Line 14 taxable at the spousal tax rate, or ~ transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 141~le at lineal rate X .0 `~ ~ ~ ~ 0 ~ 4 16. ~ ~ ~~ - 17. Amount of Line 14 taxable ° at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19. ~ ~ ~ ~` ~ ~~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505610205 1505610205 ~~„1~I 11ii11 :IItI1 C'.F~IiII1iFT[Y I. LAURA F. SMITH, of the Borough of Lemoyne, Cumberland Co*.~nty, Pennsylvania, make, publish and declare this to be my ~,ast Will and Testament, hereby revoking and making- ~;-oid` any and all former Wills by me at any time heretofore made. 1. I direct the payment of my dust debts and funeral expenses as soon after my death as-may be convenient to my Executor hereinafter na~ted . 2. I give, devise and bequeath all the rest, residue and remainder of my estate to my children, George Smith, Gary Smith and Sharon Smith, share and share alike. 3. If any of my said children shall not be living at the dine o f my death, T give , devise and- bequeath the- -share of such deceased child to the issue of such child, if. any, and in the case of no issue, thin to my surviving child or children in equal shares, the-issue of any deceased c:hild to receive the share of the parent. 4. I nominate and appoint my son, George Smith, to be the Executor of this, my Wi11. Should my son, George, fail to survive me or fail for any reason to complete the admini- stration hereof, I appoint my son, Gary Smith, to be the Executor in his stead. Should my son, Gary, fail to survive me or fail for any reason to - Eompl.ete the ,administraton_ hereof, I appoint my daughter, Sharon Smith, to be the Exe- cutrix in his stead. ..' ~ . IN WITNESS WHEREOF, I hereunto set my hand and seal r this day o f j~tn~=r~ b Q,.v~ , 197 4 . Ej~ ~ ~ -~.~ ~'" ~- ~ SEAL ) Laura F . Smith `R, FIRST CODICIL TO THE LAST L°~IiLL AND TESTAMENT OF LAURA F. SMITH 1, LAURA F. SMITH, of the Borough of Lemoyne, Cumberland Gounty, Pennsylvania, do make, publish and declare this to be the First Codicil to my Last 1~~'Jill and_ Testament dated November. ~, .1974. _ _ _ t=1RST: Paragraph 4 of the aforesaid 1lVill is hereby revoked and replaced by the following: 4, 1 hereby nominate, constitute and appoint my son, GARY SMITH and my daughter, SHARON SMITH REED to be Co-Executors of this, my Last ~"Jill • and Testament. SECOND: to all other respects, I hereby confirm and republish my Last ~J'Jill and Testament dated November 5 1974 this ~~ ay of ,July, 1936. ~ ~ Laura F. Smith The foregoing instrument ,vas in our presence signed by LAURA F. Si~11TH, and declared by her to be the First Codicil to her Last ~~Vill and Testament dated November 5, 1974. VJe, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. -._ :: rr~ ~~` ~ ~ ~+~ ~~ •l ~~~ REV-1502 EX+ (6-98) ` SCHEDI~LE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN ESTATE OF ~ u p ~ ~ s N ~.-~~ FIL1E NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value i;> defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real nrenerty which is jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ ~ ~ w ~ . FILE NUMBER ,~ /`t s~1 ~ T'ff a p ~ o !l o s'~ o All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~LE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER jit l~ ~ .~ J~~ ~ ~/~ ~ 4 ~ ' 00 S~. D Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) ~ SCNED~lLE C-1 P' CLOSELY-HELD CORPORATE © ~' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address Citv 2. Federal Employer I.D. Number 3. Type of Business 4. Business Fleporting Year TYPE TOTAL HUMBER QF NUMBER OF SNARES VALUE QF THE STOCK YotinglNon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE t}ECEt)ENT DECEDENT'S STOCK Common ~ Preferred ~ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ ti'es ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ 11'es ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Y'es ^ No If yes, Cash Surrender Value $ Net proceeds payable $ _ Owner of the rJOlicv Date of Incorporation State Zip Code Total Numk-er of Shareholders Product/Service 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? O Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Ye:s ^ No {f yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Y~~s ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- ~ ~ ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the ,year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market valueJs. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDVLE C-Z PARTNERSHIP INFORMATION REPORT uoNE ESTATE OF FILE f~UMBER ~uR~ ~~ ~~ ! 7"h< .~O/~ " oo s~"lO 1. Name of Partnership Date Business Commenced Address City 2. Federal Employer I.D. Number 3. Type of Business Product/Service Business Reporting Year State _ Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5 ~44RTN'1~lf PEfIGh,IE>hiT OF tl~tyflA€ PERC1ff1~t1E' OF 4W'i~tERBFtIP BALAMCIIl± Qf -- CAP17Al. ACCOt1iYT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $_ Owner of the policy 9 Did the decedent sell or transfer an interest in this partnership within one year prior to death or wiithin two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yeas ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for thF: year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) . ~ SCHEDULE D MORTGAGES & NOTES ~N~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT RECEIVABLE ESTATE OF FILE NUMBER ~~G!/~~ ~ sf~?~~~ ~1~ 'o6S~Z0 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) # ' IN WITNESS WHEREOF, I hereunto set my hand and seal .-, this ~ day o f,/~tn-~ b ~,~- , 19 7 4 , ~ ~~ €; ~ ~--~.~ ~ ~-~ ~ SEAL Lauxa F. Smith Signed, sealed, published and declared by the above- named Testatrix as her Last Wi11 and Testament, in the presence of us, who, at her request, a.n her presence and in the presence of each other, have hereunto subscribed our names as wa:tnesses REV-1508 EX+ (11-io) ~ Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE 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 right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ J (=,~~r a//~ ~ ~ •-~,- ~ /// ~ ~r Ulu +~~ ~ ~'e-I'' ~2~~ fir! ,~e C~,~, ~ l/ ~~' ~ ~~~~ `l~ o/p, 3~ i ~ i ~(.~ /v~ y ~ ~~C~ jwye. ,~N' ~ - ~ 1~" Iii. s7 ~ ~«.f " ~~ ~~ ~~ J TOTAL (Also enter on Line 5, RecaF~itulation) $ I ~~. ~ ~ ~ ` 4 If more space is needed, use additional sheets of paper of the same size. REV-isog EX+ (oi-io) `: pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCEIEp1~LE F ]OINTLY-OWNED PROPERTY __ ESTATE OF: FILE NUMBER: If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. C~ 8r ~4 . S~ % t~ z~! s~ z~ j /~.~ M; r! R a sac,, ~ ~ v N.. w C ~c,K ~ ~~ ~~ ddC., /°~ ~ ~oYa B. C. ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR 10INTLY HELD REAL ESTATE. DATE ()F DEATH VALUE OF ASSET 96 OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~. A. !99 M~?' awK -~e.,f g8Y3vEV~tY Sao/, 30 ~o?e 28S'o.~.e' 2. ~ X063 !~'! ~?" l~aaK ~ /~cvF'~~Z3 Iy'~ ~ 9 3N. L~ ~~ 6~~70 ~ 8/), 3`~f TOTAL (Also enter on Line 6, Recapitulation) I $ ~ ~ ~~, ~~ If more space is needed, use additional sheets of paper of the same sizE~. REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF ~ FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 CCIVER 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 CF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. Nd~ TOTAL (Also enter on line 7, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-09) ~ Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ ~S b 9ti, ~ ,2,~ Sob •~ T O .: s ~ ~~~ ~ _,,,, i. p 3~9 G ra.v~ o~.,v~ ~ G~'a.,~r ~ •~ ~ a ~r ~~~ f 7'6'0 .~ ~s-o 9 00, - ~ ~~ ~w i t'f' ~l /~trt ory~ l-e ~~~~s ~ /~CVcf~ er /~df'/Ibs., ~~F ~V+O .2 ys, ~--~ AOl 74 C,, r~~ T t ~.i'f "'s' J / ~ ~t/ ~P i~c~ ~% 7 •~ o'er r / i6"~ ~ .Z ~ . _.. r'/dw~s 3?~~ ~2 /`t yl`%l~S ~GrNeX ~ j ~orrc ~iV 6 . 3 ~ ~. M~/~/ b r B. ADMINISTRATIVE COSTS: /y~cs>~~~'e a ~i a. ~~ ~ ~ /~ ~ 7~~~ i. Personai Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: Z• Attorney Fees: 3. Family Exemption: (If 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 : R a ~ ~ ~' ~*+" O r w ~ ~ ~ 6 - C ~ N 1 ~/ ~~ C/`"' • a ~'o S• Accountant Fees: 6. Tax Return Preparer Fees: 7. If more space is needed, use additional sheets of paper of the same size. TOTAL (Also enter on Line 9, Recapitulation) ($ ~©~ $' ~~ 3Z REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNE~u~E i ~o DEBTS OF DECEDENT, C~ MORTGAGE LIABILITIES, & LIENS ESTATE OF - S % % / ~ FIL~a BED Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (01-10) ~~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RFSTDFNT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] ,~ ~ ,5' a.v ~yf ' ! i Q ~d ~ ~ ~9r b C/e~ ~ ~~ ~~ J ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 CCIVER SHEET. ~ If more space is needed, use additional sheets of paper of the same size. REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Sheet ~~~~ ESTATE OF ~~/ ~ ~ ~ FILE NUMBER ~d ~~--D !.~ /~~ S / ~ ,z..r f/ This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a. copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) - DATE OF BIRTH ~ NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) - DATE OF BIRTH ~ NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY 1S PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund trom which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Semf-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) 'REV-1644 EX+ (3-84) ~ INHERITANCE TAX ~~~ SCHEDULE "L" COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION INHERITANCE TAX RETURN RESIDENT DECEDENT OF TRUST PRINCIPAL I. Estate of ~o~~ FILE NUMBER ~~r ~~~~~ > /~'l % T/f ~~Gc/Q~ (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) Date B. Name(s) of Life Tenant(s) Date of Birth Age on date or Annuitant(s) of election C. Assets: Complete Schedule L-1 1. Real Estate $ - 2. Stocks and Bonds $ - 3. Closely Held Stock/Partnership $ - 4. Mortgages and Notes $ - 5. Cash/Misc. Personal Property $ - b. Total from Schedule L-1 D. Credits: Complete Schedule L-2 1. Unpaid Liabilities $ - 2. Unpaid Bequests $ - 3. Value of Unincludable Assets $ - 4. Total from Schedule L-2 E. Total value of trust assets (Line C-6 minus Line D-4) F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) IAlse enter on Line 7. Recaoitulationl Term of years income or annuity is payable Invasion of Corpus: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth or Annuitant(s) Age on date Term of years income corpus consumed or annuity is payable C. Corpus consumed D. Remainder factor (see Table I or Table II in Instruction Booklet) E. Taxable value of corpus consumed (Line C x Line D) (Also enter on Line 7, Recapitulation) .. Q~v.a~as ex+ I~.as- INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN ~~` ~ ~'~'~~('~ RESIDENT DECEDENT -ASSETS- FILE NUMBER I. // ~ ~, Estote of h (last Name) (First Name) (Middle Initial) II. Item No. Description Volue A. Real Estate (please describe) r I ~~ r Total value of real estate $ 0 d p O (include on Section II, Line C-1 on Schedule L) B. Stocks and Bonds (please list) ~ ' i /~ c) /tJ Total value of stocks and bonds $ D ~ ~ G (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) ~ ~ Total value of Closely Held/Partnership $ (include on Section 11, Line C-3 on Schedule L) GD. D D D. Mortgages and Notes (please list) ~G N ~ Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) 6 d • 6 C5 E. Cash and Miscellaneous Personal Property (please list) loo N~ Total value of Cash/Misc. Pers. Property $ ~ 8 (include on Section II, Line C-5 on Schedule L) ~ . 111. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1646 EX+ ,s-aa~ INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION ~~yy~~ j INHERITANCE TAX RETURN ~w~w~~e- FII F Nl1MBER s~`~// ~ ~~~ ~j ~ ~ I. Estate of ~~ ! ~ ~ " ,~ ..~____~ IFirst Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) ~ N~ Total unpaid liabilities $ - (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) /" Total unpaid bequests $ ,___ (include on Section II, Line D-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: /" ~ " Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ =_- (If more space is needed, attach additional 8'/s x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M y~ ~~ FUTURE INTEREST COMPROMISE /~~ Check Box 4a on Rev-1500 Cover Sheet ESTATE OF _ FILE NUMBER This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE: OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) COMMONWEALTH OF PENNSYLVANIA Ifl11..7Cn~-rw.,...- ~... _._ ESTATE OF SCHEDULE N SPOUSAL POVERTY CREDIT D~i~ (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94 ~~~j'~ ~ FILE NUMBER ~~ This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. • - ~ ~ ~ ~ . _ 1 Taxable Assets total from line 8 (cover sheet) ... • • , . .... ... 2. Insurance Proceeds on Life of Decedent ....... , . ... . ........ .... 1. ........ ... • Retirement Benefits ..... . .... ..................... 2. ........ .......... • Joint Assets with Spouse ..... . .... .................... 3. PA Lotte ......... 5. ry Winnings ...................... ..... ................. 4. ........ 6a. Other Nontaxable Assets: List {Atta h ..... ............................ 5 c schedule if necessa ry).. 6a. 6b. 6c. 6d. SUBTOTAL (Lines 6a, b, c, d) ........ ..... ..... 7. Total Gross Assets (Add lines 1 thru 6) .. , • , • • • .... ................ 6. 8. Total Actual Liabilities ..... • . .. • , • . • . • 9- Net Value of Estate (Subtract line 8 fr If line 9 is greater than $200 0 ~ ~ ~ • • ~ ' • • • " " " " ' • • • - • • • • • • • 8• , 00 -STOP. The estate is not eligible t 9. o claim the credit If • ~ ~ • ~ • • ~ . n ot, continue to Part 11. -_ ~ ~ income: 1. TAX YEAR: 19 2• TAX YEAR: 19 3 T a. Spouse ...... 1a . , .... . 2a. b• Decedent ........ 1b 3a. . 2b. c. Joint ...... , • 1c 3b. •••. . 2c. d• Tax Exempt Income .. 1 d. 3c. e . Other Income not 2d. listed above ........ 1 e 3d. 2e. f. Total ....... 1 f 3e. • . . 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Incom f 2f 3f. e rom above: (1 f) + (2f) + (3f) _ 4b. Average Joint Exemption Income .... . If line 4(b) is greater than $40.000 -STOP. The asrata ;~ ,,,,...,:_:~,_ . ~ . •. • ~ ~ • • • • • • • ' ' ' ' • • • Insert amount of taxable transfers to spouse or $100,000, whichever is less .... . 2• Multiply by credit percentage (see instructions) .... • • • . ...,.. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . ...................... 4• For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ..... . 5• Multiply line 3 by line 4 and enter the total here. This is the amount of the No president Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet.. . ....~ (- 3) rt 111. REV-1649 EX ~ (t-97) SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN -(SPOUSAL DISTRIBUTIONS) RESIDENT DECEDENT _ ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance 8 Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and; a, The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to bE; included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the dotal value of the trust or similar arran ement. PART A: Enter the description and value of a!I interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arranaement. (If more space is needed, insert additional sheets of the same size) REV +oG9 EY, < ;t-E7) l COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE d ELECTlt~N UNDER SEC. 9'! 13(A} ~SP~USAL DlSTRlBUTlONS~ ~ O~ ESTATE ©F FILE NUMBER loo not complete this schedule unless use estate is making the election to tax assets under Section 9'1'13(Ap of the Inheritance ~ Estate Tax Act. !f the election applies to more than one trust or similar arrangement: a separate form must be filed for each trust. This election applies to the _ _ __ _ ..____ ____ _ ___ ____ Trust (manta{. residua! A. B. B,vL--pass; Unified Credit; etc.l. IT a irUSi. or similar arrangerr3ent ri~t5 tie r~quirtrllierli5 tit ~Gtit7n ~ s'i3jfij, alit: a. ThQ trr~Si nr similar arrangement iS listPti nn Sr_.hPd~!!e U, and h, Thp val+aa of ±ha tn_tst nr similar arrannpmpnt is PntPrPCi in whnlQ nr in Hart ac an asSPt nn Sc~hPdi,dP n, inen Ztie Iratt5t8ror'3 persOriai iept'~eiitatlve -iiay ~~C;iltCaily ISe;liiiSy I~ie tt"USt jail t1t a 3iaCtiOi'lai pOriitill Ui percentag@i tG iJ~ ItlCltit~~ ill the el~C;tl0ri tti have Suctl trust or similar property treated as a taxable transfer in this estate. !f less than the entire value of the trust or s!mllar property !s included as a taxable transfer on Schedule 0, the n~?rcnn~! ranrasent~tiva 8ha1) ~ Cr~tzSiderad to hatre made the t?lertion nnly ac to a fraMipn pf thg tn~st to gimilar arrangement: ThP n+lfTmpratt3r 4f this fraCtiQn iS grn~a! try tha ar{t~t#~t of tha tn~ct r!r ~i!??iiar arran~samgnt inril~ri~i as a taxahlg aS$P_.t !1t1 S(;hP_.d+~lQ Q. Tht? dQnnminatnr ig pniia! to tha tntal yahip of thP. tn~ct nr Similar arP?Intz Pn#. ~f'1f~ i i'1: CIIiFCi iiiiC LI~JGEi~;I.[t,Jl:: Gff4 i~ai-t,IC uF all i:33tGtG~l::, i1UE~! tetAilFJIC Lf3Iu iµsi39i-iraiiciuiGS i~yeais.sl~~a i1i ttit~ctifuE€, v~8eie,+i }iu~~ lit iei~ u~~:~iiciti'a surviving spc~~tse under a Section 91 ; 3 ~A} trust or similar arrangement. ~ESCP.{PTtGN l VAL~~ .-r°'f ~ :~ ~; , ~< ~,,.,_ ,. Part A Total ~ $ PART B: Enter the description and ualcte of all interests included in Part A #or which the Section 9'113 (A) election to tax is being made. DESCRtPTit?N VALUE -., ~~ Part B Total I j!~ rriore space is ile%t1e~, 1; )salt aoaltlonal srieets OS tale Same size j