HomeMy WebLinkAbout09-10-11~-
1505610140
REV-1500 EX (°~-,°,
PA Department of Revenue
Bureau of Individual Taxes OFFICIAL USE ONLY
PO BOX 28osD1 INHERITANCE TAX RETURN County Code Year File Number
Harrisbur PA 17128-0601 RESIDENT DECEDENT 2 1 1 1
ENTER DECEDENT INFORMATION BELOW 0 6 9 9
Social Security Number
Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 6 8 2 6 5 0 7 2 0 6 1 0 2 0 1 1 0 3 1 4 :L 9 3 2
Decedent's Last Name
B L A Suffix Decedent's First Name
C K MI
(If Applicable) Enter Surviving Spouse's Information Below R A Y M O N D S
Spouse's Last Name
Suffix Spouse's First Nsime
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
FILL IN APPROPRIATE OVALS BELOW REGISTER OF VIJILLS
OX 1. Original Return
2. Supplemental Return
4. Limited Estate
~
4a. Future Interest Com 3. Remainder Return (date of death
prior to 12-13-82)
^X
6. Decedent Died Testate
~ promise (date of ~
death after 12-12-82)
D
~ 5. Federal Estate Tax Return Required
(Attach Copy of Will)
9. Litigation Proceeds Received
~ •
ecedent Maintained a Living Trust _
(Attach Copy of Trust)
10
8. Total Number of Safe Deposit Boxes
. Spousal Poverty Credit (date of death
between 12-31-91 and 1
~
11.
E
l
ction to tax unde
S
CORRESPt7NDFntT _ rwe ~~..r.,.......__ _ -1-95) r
~
µ
r
ec. 9113(A)
Name
-""'" "~ """ "'~~ ~ rst ~umPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
R O G E R g Daytime Telephgtl~ Number
I R W I N E S Q U I R E 7 1 7 2 `'~~9 2 c~., 5 3 x'
~n
REGISTER OF lIItLS USE WILY
First line of address c, ? ~ '~ ~ ,
& M c K N I G H T P C.
Second line of address i
~ _ ~jf~G
6 0 W E' S T P O M F R E T 1
S T R E E
City or Post Office
C A R L I S L E
State T
ZIP Code DATE FILED
P A 1 7 0 1 3
Correspondent's a-mail address:
Under penalties of oeriuro i ~o,.i~.~ .~_. ~ ~ _
re urn, including accompanying schedules and statements, and to the best of my knowledge and belief,
~c 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 E SON RESPON~BLE F FILING RETURN
! DAT
ADDRESS y/~ Fj/
60 WEST PO T BEET /
SIGNATUREOFP E T CARLISLE PA 17013
ESENTATIVE
ADDRESS
~ _ ATE ~
60 WEST POMFRET
ET CARLISLE
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140
PA 17013
1505610140
Dh2D'C95O5'L
1 Oh20'C95D5'C
Z aplS
1N3WJltld213A0 Ntl ~O aNf1~321 tl °JNI1S3(1D3213atl (lOA ~I ltlAO 3F Il NI lll~ OZ
............................ 3(10 Xtll '6L
Z Q• 0 'L h 2 `C ....
'6L ........
s~~ x a;e~ e~alepoo;e
'8l ~[ E E `~ E ~ algexel4L aw- }olunowy '8L
O D' Z 6 `~ Z~' X ate 6uligls le
"
'LL Ll
0 D 0 algexe} yl. auf l;o lunowy
0 0 ° 0 9v0' X ilea Ieawl le
s~ Z E ' 6 `C h 'C Z 2 algexe; 4L ouri }o lunowy '9L
Z Q ' E 'C 2 2 'C p' X (Z~6)(e)
'S ~ 0 0 ' 0 9l l6 'oaS ~aF un spa}sued
0 0 ° 0 ~o 'alea xel le mods ay; le
algexe; 4l au l;o lunowy 'S6
S31tl21 3lgtlOllddtl 210 SNOIlO(kllSNl 33S - NO Iltll(lOltlO Xtll
~---
"
...
4l
(E 1, aull snww Z l au!l) Xel o;;aafgr g antes 3aN
...................
Q 9 °2 E Z 2 Z 2 .41
............ . .. (~ alnpayoS) apew uaaq lou set' xel ~; uol;oala ue
uaruuaanoO pie atgel!~ey~ '£L
• £L yoiynn ~o} slsn~l E666 oaSlslsanbag Iel
awl) ale;s3;o anteglaN 'Z6
..
(~~ aull snulw g
...................
B 9' 2 E Z 2 Z 2 Zl
suo 3onPa4 lelol L L
(OL pue 6 saw} lelol)
..
Q 9' Z 2 2 Q 2 ~t _. .
ua aoaQ }o sigatJ O l
(l alnpayoS) sua!l pue 'sal;plgell a6e6yoW '1 p
5 9• h h E 2 Ol
ue sas uadx3 le~aun~ 6
(H alnpayoS) slso~ andle~lslwwPtl P
E 0' E Q Q S 2 6
......... (L y6nwyl 6 sau!l lelo;) s;asst' sso~O lelol g
..............
9 E° D 9 6 0 D E 8 . (~ alnpayoS)
~ palsanba~ 6u!II!8 ale~edag '
spa s ie~ sonln-~a;ut "L
b 1
s
'
E 2° 'C 9 5 S S L lW
8
~S
R~adad alegad- N snoauepao
a n a o ~( ada i paunnO ~lluloP 'g
ale~edaS ~ (~ I P y S) ~
6
.9 upilg
pa;sanbatt
'C E ~ E `C E 2 ue s;Iso iaa ~lueg 'used 'S
(3 alnpayoS) l~}~adad leuos~ad snoauellaoslW p
2 Q 5 Q 0 6 h 'C 5 ...... (d alnpayoS) algenlaoa~ salot I pue sa6e63JOW '4
4
. (~ alnpayog) dlys~olaudad-aloS ~o dlys~au~ed 'uolle~odio~ plaH Rlasol~ "£
E
...... (8 alnpayoS) s ~uoe pue s~loolS Z
° Z ....
.................................... (tl amps 4oS) alels3 lean L
D D° D 0 0 5 6 .
NOlltllfilldtl~32i
it ~ `018 ' S Q N 0 W ~ d ~ aweN s,3~apa~a4
2 2 0 5 9 2 8 9 2
x3 0~ is ~-n3a
~agwnN ~(}unoag lelooS s,luapaoaa
Oh2D`C95O5'C
i