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Home My WebLink About08-22-11 J ~ EX ~ REV-1500 OFFICIAL USE ONLY' PA Department of Revenue Pennsylvania - Bureau of Individual Taxes DEPAFTMENTOFNEVENUE County Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN 2 Harrisburg, PA 1128-o6oi _ RESIDENT DECEDENT ~ ~ ~ ~ ~ ~ J7 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 (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 ~+I 1 G REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ Original Return O Supplemental Return C~ Remainder Return (Date of Death Prior to p Limited Estate fl 4a. Future Interest Compromise (date of C7 Federal Estate Tax Return Required death after Q Decedent Died Testate O Decedent Maintained a Living Trust ~ Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O Litigation Proceeds Received C, Spousal Poverty Credit (Date of Death CO Election to Tax under Sec. 9113(A) Between and (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~ ~ L G~ tc! r%1_ u ~ 1/Q G 1 to ~ (v~ F:EGISTER OF WILLS USE ONLY r ~ :t'7 First Line of Address C7 E ` ' ' 1 i G ' r- 1 r Second Line of Address ~J,j~ s" c~;~;~ -n _ City or Post Office State ZIP Code :~~E FILED ~ r--- Correspondent's a-mail address: ~ ~ ~ Y ~ ~ ~ ~ ~ i 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. SIGNAT OF P RSON RESP I LING RETURN ~ DATE ~ c~ c _ ADD ~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS N~~- ~r PLEASE USE ORIGINAL FORM ONLY Side 1 J REV-1500 EX Decedent's Soc ial Security" Neu/tuber Decedent's Name: ~ U G ~ ~ ~ v b ~ m__ , ,.,.w _ _ _ _ _ _ . ......w.. -.~.µti_~.....w..,.._..a ....~....~.....~_...._._.......,,,..~s....._...~..... RECAPITULATION Real Estate (Schedule A) Stocks and Bonds (Schedule B) Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) Mortgages and Notes Receivable (Schedule D) • r Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... ~ ~~Q • Jointly Owned Property (Schedule F) ~ Separate Billing Requested ~ C ~ ~ ~ ' s Inter-Vivos Transfers & IVliscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ Total Gross Assets (total Lines 1 through ~ ~ 1 ~ r. - Funeral Ex enses and Administrative Costs Schedule H Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ~ . j Total Deductions (total Lines 9 and e ~ ~ ~ ~ ~ , Net Value of Estate (Line 8 minus Line . ~ ~ ~ ~ Charitable and Governmental Bequests/Sec Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line minus Line ( _ _ _ _ C ~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ Amount of Line taxable at the spousal tax rate, or transfers under Sec. (a)(1.2) X ~ ~ p Amount of Line taxable ' at Pineal rate X _ Amount of Line taxable at sibling rate X • Amount of Line taxable at collateral rate X • • TAX DUE ` ej ~ c~ FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 J cv Page 3 File Number Decedent's Complete Address: DECEaENTS NAME / ~ ~l,C ~ ~/~t~C v v ~ STREET ADDRESS S u~ S t~ 1 ~ r _v.C s STATE ,`-ZIP - - CITY L ~ rt r~ , c s ~ ~ ~ f yb~~ ~1`,GS'f Tax Payments and Credits: Tax Due (Page Line ~ ~ Gn Credits/Payrnents A. Prior Payments _ _ E3. Discount Total Credits (A + B) Interest If Line 2 is greater than Line 1 + Line enter the difference. This is the OVERPAYMENT Fill in avai an Page Line to request a refund. If Line 1 + Line 3 is greater than Line enter the difference. This is the TAX DUE. ~ , o bake check payable ta: REGISTER +QF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Did decedent make a transfer and: Yes No a. retain the use oc income of the property transferred ? b. retain the right to designate who shah use ~e property transferred or its income ? c. retain a reversionary interest ? d. receive the promise for Life of either payments, benefits or care? ? If death occurred after Dec. did decedent transfer property within one year of death without receiving adequate consideration? ? Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ? Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ? IF THE ANSWER TO ANY OE THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Far dates of death on or after Juiy and before ,fan. the tax rate imposed on the net vaiue of transfers to or far the use of the surviving spouse is 3 percent P.S. (a) (i)J. For dates of death on or after Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent P.S. (a) (ii)J. 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 benefiaary. For dates of death on or after July • The tax rate impased on the net value of transfers from a deceased child 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 P.S. §9116(a)(1.2)j. • The tax rate imposed on the net vaiue of transfers to or for the use of the decedent's lineal benefraaries is percent, except as noted in 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 percent P.S. §9116(a)(1.3)]. Asibling is defined, under Section as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1511 EX+ (10-D9) ~ pennsytvania SCHEDULE H DEPARTMENT Of REVENUE FUNERAL EXPENSES AND INFIERTfANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF 1 FI~L9E~iN/U~jM~BE~R(~.~ Decedent's debts must be reported on Schedule i. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: r ~~~~c,'~~ Gym ~ e ~ ~ U 1 B. ADMINISTRATIVE COSTS: Personal Representative Commissions: Names} of Personal Representative(s) Street Address City _ State ZIP Years} Commission Paid: Attorney Fees: 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 Probate Fees: Accountant Fees: t Tax Return Preparer Fees: TOTAL Aldo enter on Line Reca itulation $ t p ) fib" If more space is needed, use additions{ sheets of paper of the same size. REV-1513 EX+ ~ pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: L~~~rn ~ ~ ~ ~ ~ ~ ~ FILE NUMBER: ~ t 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. (a) ~%J'~ j! G ~t~/ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES THROUGH OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A, SPOUSAL DISTRIBUTIONS UNDER SECTION FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. REV-1502 EX+ ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is 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 property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION i TOTAL (A1so enter on Line Recapitulation.) $ If more space is needed, insert additional sheets of the same size. REV-1503 EX+ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-awned with right of survivor hip must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX + SCHEDULE C COMMONWEALTH 4F PENNSYLVANIA CLOSELY•HELD CORPORATION, INHERITANCE TAX RETURN PARTNERSHIP orSOLE-PROPRIETORSHIP RESIDENT DECEDENT ESTATE OF FILE NUMBER / Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held torpor tion/partnership interest of the decedent, other than asole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH r- TOTAL (Also enter on line Recapitulation} $ (If more space is needed, insert additional sheets of the same size) ~v-~sosoc * {~-s~ SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLC)SEL i -HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER ~ Name of Corporation State of Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders Federal Employer I.D. Number Business Reporting Year Type of Business ProducUService TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting /Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. Was the decedent employed by the Corporation? ? Yes ? No If yes, Position Annual Salary $ Time Devoted to Business Was the Corporation indebted to the decedent? ? Yes ? No If yes, provide amount of indebtedness $ Was there life insurance payable to the corporation upon the death of the decedent? ? Yes ? No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to ? Yes ? No If yes, ? Transfer ? Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for addit+ona{transfers andlor sales. Was there a written shareholder's agreement in effect at the time of the decedent's death? ? Yes ? No If yes, provide a copy of the agreement. Was the decedent's stock sold? ? Yes ? No If yes, provide a copy of the agreement of sale, etc. 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. Did the corporation have an interest in other corporations or partnerships? ? Yes ? No If yes, report the necessary information on a separate sheet, including aSchedule C-1 or C-2 for each interest. THE FOLk.CitVVfNG INFt~RI~ATIt3N MUST 8E SU~ITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stack. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 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 values. 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. ~~M... r.1 REV-1506 EX+ SCHEDt~lLE C-Z PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPC?RT RESIDENT DECEDENT ESTATE OF FILE NUMBE d Name a artnership Date Business Commenced Address Business Reporting Year City State Zip Code Federal Employer I.D. Number Type of Business ProductlService Decedent was a ? General ? Limited partner. If decedent was a limited partner, provide initial investment $ 5 , _ , ~ t~~t~CEN7 ~ PERCENT ; ~ BAL~k~lCE OF.: z. ~ pAATNER:NAME ~ -4F°1NC4M~ CfF-411VNEpSHIP;; CAPITAL AGC(JUNT > ' A. B. C. D. Value of the decedent's interest $ Was the Partnership indebted to the decedent? ? Yes ? No If yes, provide amount of indebtedness $ Was there life insurance payable to the partnership upon the death of the decedent? ? Yes ? No 1f yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to ? Yes ? No If yes, ? Transfer ? Sate Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. Was there a written partnership agreement in effect at the time of the decedent's death? ? Yes ? No If yes, provide a copy of the agreement. Was the decedent's partnership interest sold? ? Yes ? No if yes, provide a copy of the agreement of sale, etc. Was the partnership dissolved or liquidated after the decedent's death? ? Yes ? Na If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. Was the decedent related to any of the partners? ? Yes ? No If yes, explain 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 for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addressles and estimated fair market value/s. 1f 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+ ~ vCHEDULE .D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF _ FILE NUMBER ~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line Recapitulations $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ SCHEDULE G ~ ` pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE IWUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1540 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH °!o OF DECD'S EXCLUSION TAXABLE INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE) VALUE ~ ' TOTAL (Also enter on Line Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. i REV-1512 EX+ (12-d8) ~ ~ Pennsylvania .SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT FIL ~41~M ESTATE OF r---~ Report debts incurred by the decedent prior to death that remained unpai a the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on Line Recapitulation) $ If more space is needed, insert additional sheets of the same size. RE1/-15081JC+ s pennsylvarria SC~IEOI~LE E DEPARTMENT of REVENUE CASH, 6ANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE Of: FILE NUMBER: cx,E~ V t°! C c ~ Include the proceeds of litigation and the date the proceeds were received by the estate. A8 property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DE5CRIPTION OF DEATH TOTAL .(Also enter on Une Recapitulation) $ ~~a ; If more space is needed, use additional sheets of paper of the same site. REV-1509 EX+ (Di-10) ~ Pennsylvania SC~IEptlLE F DEPARTMENT OF REVENUE - - INHERrrANCE•TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: If an asset became jointly owned within one year of the decedents date of death, it must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. C. ' 30INTLY OWNED PROPERTY: ' LETTER DATE DESCRIPTION OF PROPERTY OF DATE OF DEATH I1HN FOR J(HNT MADE INCLUDE NAME aF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DEC®B'fT5 VALUE OF - NUMBBL TENANT ]DINT IDENTIFYING NUMBfjER. ATTACLH D,lg~fFOR JOU/ft~LY H9jD REAL ESTATE. VALUE OF ASSET ITT DK®8JT'S INiERC3t' A. ~ /lr~ / /!/fit y+n ~-y ~ (S' ~ /~~G G~ /r-ftc'~`7 - C7 S~. Fjt7 , jl~~ , ~ ~ G~ f - - - TOTAL (Aso enter on lane RecapitLllation) $ If more space is needed, use additional sheets of paper of the same size. - i`l