HomeMy WebLinkAbout08-01-11 505610101
REV-1500 ex `°'-'°' '
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania _
Bureau of Individual Taxes of>a' EN, of County Code Year File Number
PO BOX z8D6oi pINHERITANCE TAX RETURN
Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT °~ ~ ~, ~ ~ `~ i 7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
~~~~~36~~ ~ ~<~a~wf ®7~~~~~-
Decedent's L
st Name
a Suffix D
eced
nt's First Name MI
e
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(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
~ ~ `~ ~ 3 ~ ~' ~ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~~ 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)
O 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 Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
First line of address
Second line of address
City or Post Office
State
ZIP Code
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RIEGISTEF~;D€~1IILLS USE,ONLV' ;?.
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CJATE FILED o-~:`
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Correspondent's a-mail address: ~1 l Z ~ /G~F~Q ~~ ~ /~Cf~,S~ ~ /(~~-~T
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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.
SIGNATURE PER ON RESPON,S;IB~LE~O~R FILING RETURN s~~~_~ DATE
ADDRESS J // ~ '
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name:
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. 1. •
2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~ ~ 5 a • [~
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. a Q J 3 / • ~0 (p
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. f! ? S (~ Q ('~ • (~
7. Inter-Vivos Transfers £~ Miscellaneous Non-Probate Property
{Schedule G) p Se
arate Billin
Re
uested
7
~C
' ~
+ ~ ~ ~ J
~ ~
......
p
g
q .. ,
,
. ~
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 1 ~} (~ ~ ~~ ~ O . ~ c}
9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ' 3 L` ~ ~
1 7
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10.
11. Total Deductions (total Lines 9 and 10) ............................... .. 11. S
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12.
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. ~ ~) ~ ~ 1.{ ~ Q . d
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(L2) X .0~ O• ~ v 15. •
16. Amount of Line 14 taxable
at lineal rate X .0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 • 17.
18. Amount of Line 14 taxable
at collateral rate X .1 `i • 18. •
19. TAX DUE ....................................................... ..19.' d • ~ ~.~
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610105 1505610105
REV-150s EX+ (6-98)
~ ~
_. SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
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-ewe Ex * (+an
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
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
~ . So v r-_R ~ ~ ~N j{3A IV jr~
~ ~ 1 ! ~ ~.~
L~~~~s~r: ~ pp ~~ ~ 13
Nr-_~v+ ~~~ ~ Pw 1 ~~`t I
3 r~c~tit~r~ ~-(~v ~Z~*Jb ~ 3 00 , ~~
~ , h~~* spa r~, ~~HL r~~-NCr2 ~.oo~ ~s vca .aa
TOTAL (Also enter on line 5, Recapitulation) I $ a (~ 7~ ~ c (o
i
(If more space is needed, insert additional sheets of the same size)
REV~1509 EX ~ (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE F
JOINTLY-OWNED PROPERTY
FILE NUMBER
If an asset was made joint within one year of the decedent's date of death, k must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME I ADDRESS I RELATIONSHIP TO DECEDENT
A.
B.
C.
JOINTLY-OWNED PROPERTY:
~ v~tcwa~~ P~~r~
L~aR.c..I 5~ r--_ ~ PA ~7~~~ 5
!-Iu s B ~~
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 jointly-held real estate.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
~. A. auto(, ~{ Gft-ccwc>r,~ Pc,~GF sU`~ r Ste, c~c~
K~ ~1F
C. f+RL, l~ c r ~ P~ ~ 7v r 5 3 ~,
b ~ R 5 - (~t.~ JJ ~ A /l~ t.C
Lc:~~" °v ~ (pGC>C;Sf U
-~
~. ~ ~~~ (~-~-~~~,E ; Y Fv~: ~-~ o~ Si1 ~v, o~~.~ Saba ~ ~ ~ ocx
TOTAL (Also enter on line 6, Recapitulation) I $ ~~~ (xjU
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX ~ (137)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERTY
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 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
iNauDETHENAraEOFTHETRANSFEREE THEiRREU,noNSHiPTODECEOENTAnDTRE DATE OF TRANSFER.
ATTACH A COPY OF THE DEED FOR REAL ESTATE .
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST
EXCLUSION
~iFAPPUCAeLE
TAXABLE VALUE
,. ~~ F_(~ ~ )~? F-T ifcrr~i~(~-~T '?~S~ ~~`f.~1 /c~c~ 7&3 ~~y 7~
p ~,r~ -r M ~,ir,N ~ r-- ~ r
T N G- ('mot-`~- i ~~ n~ r ~~ r f~ cLVCtc~; ~ ~ ~, 9~Z,a~ t ,/ v r ~~~~>~~~
y ~ 1 Cr ~~ (~ (? 1 AJ Cr j'I 1 G- ?'I S C` K UO (__.
R ~ ~ . /~
F
~
~
.
S f C 1%
r~% ~~- r(,~= ,ti,r-tit.
TOTAL (Also enter on line 7, Recapitulation) ~ $
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT _
A. FUNERAL EXPENSES:
t. L HU/Yi
1..6-G-Ajz Fug F/2~t 3 ~ ~ , 7:
e. 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: (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 $
(If more space is needed, insert additional sheets of the same size)
RE.V-1~ 00 EX Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
STREET ADDRESS
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B) (1)
(~3)
(`t)
(•~)
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 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, benefts 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 benefciary 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(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 or adoption.