HomeMy WebLinkAbout08-29-11 1505610101
REV-1500 EX (Oi-10)
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
DEPARTMENT OF REVENUE County Code Year File Number
Bureau of Individual Taxes
PO BOX 280601 INHERITANCE TAX RETURN ,~ ~ ~ ~ ~ 1
I
Harrisburg, PA 17128-0601 RESIDENT DECEDENT p~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
~~.~~1~`y~~~2~7~ v ~z2zc,~v ~so~t~s~
Decedent's Last Name Suffix Decedent's First Name MI
,.q
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
z Suffix Spouse's First Name MI
.... >.
Spouse's Social Security Number
=° ~~~~-~~~~°~- ~ ° T w,,,• ~ ~ - - ~ ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
. 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
~ 6. Decedent Died Testate
(Attach Copy of Will)
O 9. Litigation Proceeds Received
O 4a. Future Interest Compromise I;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)
State ZIP Code
i ~ C 1 r
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
~~ _ . f
c~
REGISTE~~ ft~S US~QNLY ~ ~ ~'
',_ r--
L, _ _
First line of address ~~ m. "~
~ ~_.~
Second line of address ~..`~, ---d C___ i~~ ~-~
City or Post Office
~~-~ ~il~
Correspondent's a-mail address:
DATE FILED
Under penalties of perjury, I declare that I have examined this return, including accompanying srhedules and statements, and to the best of my knowledge and belief,
it ~ue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
RE OF PER~Q7V RESPONSIBLE FOR FILING RETURN
DRESS
-~ - ~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
1
prior to 12-13-82)
O 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
-/~.
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101
1505610101
REV-1500 EX Page 3
Decedent's Complete Address:
STREET ADDRESS
CITY
Tax Payments and Credits:
1 • Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
8. Discount ---
File Number
STATE ~ -- ZIP
3. Interest
Total Credits (A + B) (2)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OV
Fill in oval on gage 2, Line 20 to request a refund. ERf'AYMENT. (3)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the T (4)
AX QUE.
(5) - ( ~1
Make check payable to: REGISTER OF
~..
-~'~,s~i. 4 Rte" ~c
WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTION ~~~
S BY PLACING AN "X" IN THE APPR
1. Did decedent make a transfer and: OPRIATE BLOCKS
a. retain the use or income of the roe transferred• ...................
Yes
b. retain P P ~ No
the ri ht to d •••••••~•~•
.....................................................
9 esignate who shall use the ro ~ ' ~' ~ '
c. retain a reversions P PedY transferred or its income : ...................
ry interest• or.
d. receive the r ~•~'~•"""""""""~
p omise for life ......................................................................
of either payments, benefits or ~ •••••••••••• ^
2. If death occurred after Dec. 12 care ...............
.........................................
, 1982, did decedent transfer property within one year of death
without receivin
g adequate consideration
3. Did decedent o ............................................................................................................... ^
wn 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- robs
contains a beneficiary designation? .,.....__ P to property, which
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS Y ...................................................................................... ^
~$~ - `~ ES, YOU MUST COMPLETE SCHEDULE G AND FILE
f, k~.~; r '.fir., "' g ~::.tt.f ~,
`~ ~~ ASP RT OF RET
For dates of death on or after July 1, 1994, and be ~ ~~ • ~ ~~ ~~`~ ~ " `f'=. ~~ °~ " ; IT THE URN.
~.; ~~~,:
3 percent (72 P.S. §9116 (a) (1.1) (i)j, fore Jan. 1, 1995, the tax rate imposed on the net value of transfersu £, .,.-~~~~ ~~ ~ ~ .~
-or dates of death on or after Jan. 1 19 to or for the use of the surviving spouse is
95, the tax rate imposed on the net value of transfers to or for th
72 I?S. §9116 (a) (1.1) (ii)j. The statute does not exempt a transfer to a
fling a tax return are still applicable even if the surviving spouse is the on a use of the surviving spouse is 0 percent
surviving spouse from tax, and the statutory requirements for disclosure of
or dates of death on or after July 1, 2000: IY beneficiary. assets and
The tax rate imposed on the net value of transfers from a deceased c '
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116 a 1.2
hiid 21 years of age or younger at death to or for the use of a natural
The tax rate imposed on the net value of transfers to or for ()( )j parent, an
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. the use of the decedent's lineal beneficiaries '
The tax rate imposed on the net value of transfers to or for the use of th is 4.5 Percent, except as noted in
Section 9102, as an individual who has at least one parent in common wi
e decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)j. A siblin is deft
th the decedent, whether by blood or adoption, g ned, under
J
15056],0],05
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: ~ ) 1 /~ / ~ 2 I ~ Gj
RECAPITULATION l `7 C~
1. Real Estate (Schedule A) ............................................. 1. 0'
2. Stocks and Bonds (Schedule B) ....................................... ,
2. ~ d ' ~.~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
- ~" ~ ~
4. Mortgages and Notes Receivable (Schedule D) ........................... 4. b , ~
-.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. O
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property - ~ ~ ~ - - ~ ~~ '"'"
(Schedule G) p Separate Billing Requested........ 7.
~~~~~
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ,
~0
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9.
!- Q
., - ., ;. _
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10.
U~ o O
~- .; .
::.
11. Total Deductions (total Lines 9 and 10) ................................. 11.
~~va
.~
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. U ~: ~
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.
~~~,~
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES `""""'""""
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 . _ rt, ~. _ ... "., ,
(a)(1.2) X .0
16. Amount of Line 14 taxable ~ ~ ~ ~ ~ ~:~ ~ ~ Y ;
''r h{max ~ rK, ~ ~ # ;~:
at lineal rate X .0 ._ ~~ O ~ ~ '` ~ - ''
. 16.
17. Amount of Line 14 taxable ~ - M` ° ~ ~ ,,~z~~ F ~ ~ y :_~~ ~:-~ ~ , ~~,- ,~ ° ~ ~.
.. ~.
at sibling rate X .12 ~ ~ ~ ~ Y`~ ~ ~ -
18. Amount of Line 14 taxable ~..~~~,~ _,~ < ~~:~~ r i F~: ~., ~ .~~~,~, <,.
at collateral rate X .15 ~ ~ ~ ~ ~ Q ~'
~~ 18.
__ ~..~. ~. _ ~ y -~ ,
y.~ `~.~ .`s`ue :v'h~°'~~i. ~.~~..~- _`~.74= .f.
" ~~
19. TAX DUE ......................................................... 19. ~. ~ ~ ~,,
~.~. <.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105 15056101,05
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