The URL can be used to link to this page

Home My WebLink About09-16-11J 1505610101 REV-1500 Ext°1.1°~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes °"AA,ME"'°`p`"`"°` County Code Year File Number PO BOX 28D6oi INHERITANCE TAX RETURN Harrisburg, PA 1'7128-o6oi RESIDENT DECEDENT ~_ ENTER DECEDENT INFORMATION BELOW `~' ~ ~~ Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY a~~ ~ Ca ~ y a~ (~Co~~ ~~i ~ aye ~i 9 ~ Decedent's Last Name Suffix Decedent's First Name W~~,`~~~~ MI ~~~~o~~ ~ .~3 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffi Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return x Spouse s First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return C~ 3. Remainder Return (date of death O 4. Limited Estate prior to 12-13-82) O 4a. Future Interest Compromise (date of C~ 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Livin Trust (Attach Copy of Will) (Attach Copy of Trust) g ~ 8. Total Number of Safe Deposit Boxes O 9. Litigation Proceeds Received O 10. S ousal Poverty Credit (date of death p CJ 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 TO: Name n ~ H a Daytime Telephone Number 1D L('r~ ON tip- M~C~~ f 35~ ~ 7~ ~9S REGISTER OF WILLS USE ONLY First line of address ,.`OO C~(~.ov ~ sT ~E E~r Second line of address C7 ~ - City or Post Office ~ ~> r- ~ - State ZIP Code QA'T>)TFILED-- ~ C:~ Correspondent's a-mail address: _ i - - u ~ - ~ - ~' ~0.1fu nn ~ ~e.~ i~ (Jrl~,~~er~~n . V1 ~ ~ --~ ... ; -,-, Under penalties of perjury, I declare that I have examined this return, inclu ing accompanying schedules and statements, and to the best of my kno. ~dge and belleCf,3 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. SIGNATUR OF PERSON RESPONSIBLE FOR FILING RETURN - f~, DATE ADDRESS - ___ ~/ _ - '~ .r ~ ] SIGNATURE OF PREPARER OT- F{E~ HqN REPRESENTATIVE ADDRESS DATE ^ir PLEASE USE ORIGINAL FORM ONLY L 1505610101 Side 1 1505610101 J i~ ~~ J 7,5056201,05 REV-1500 EX Decedent's Social Securi y 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. 4. Mortgages and Notes Receivable (Schedule D) .......... .. ~3~:~.3•~C~ 5 Gash, Bank Deposits and Miscellaneous Personal Property (Schedule E .. 5 ..... . . Se crate Billing Requested .. 6. Jointly Owned Property (Schedule F) ® P .. .. 6. 7. Inter-Vivos Transfers & Miscellaneous Noon-Prso PatraterBiling Requested.. ...... 7. (Schedule G) 8 ~ ~ `~ S 3 . 8. Total Gross Assets (total Lines 1 through 7) .. .. ___ __._____~ _~._ - 9. Funeral Expenses and AdminisUative Costs (Scheduie H) . 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ 10. '.;-, . . 1 i, Total Deductions (total Lines 9 ar!d 1 ~ 11 12 a ~j ~3'jLQ 12. Net Value of Estate (Line 8 minus Line 11) ... Charitable and Governmental BequestslSec 9113 Trusts for which ? 3 ~ ~ ~ - 13. . an election to tax has not been made (Schedule J) .. . 12 minus Line 13) . i ne 14. Net Value Subject to Tax (L TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES I5. Amouni 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 taxable ~ `` 16. ~ ~ ,~ at lineal rate X .0.~~ 17. Amount of Line 14 taxable ~ 17 • at sibling rate X .12 18. Amount of Line 14 taxable • 18 at co!!ateral rate X .15 ~ (jlj`~'~ .... 19. ... 19. TAX DUE ......................... . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O S+de 2 150561010!. 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: Pile Number STREET ADDRESS ~ 1~-~5 - --- - -- 1 - - - - - clrv _- __ Y ~ i~ t51~ _ - _ __ _ - I STATE ~~ 'ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments .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. (~) ___~ (~ ~ Cry ~ o 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 inc;ome : ....................................... .. ^ c. retain a reversionary interest; or .......................................................................................................................... ^ 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. Cid 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 tlesignation? ........................................................................................................................ ^ 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)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 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)j. • 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. ~d (1) J . 0 ~' y ~'~ Total Credits (A + g) (2) _ ~ 3 : oC~ (3) (4) SCHEDULE E ~ "_~~~,,, ~ ~~- ~~_~_ ~.,<.r t CASH, BANK DEPOSITS, & MISC. ~ ~~ - - `"~~° ~ PERSONAL PROPERTY ESTATE OF ~ __ t .` -- .--.3 FCLE NUMBER ~~ Include r^e proceeds ci Litigator anC the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must 4e disclosed on Schedule F.F. ~~TE4vt -- _ m 'v`'~,?EtK E C~ '+'ALU~ ~;T GATE G c ;Frjr;t.; f ----- --'-'-- ' t ' 1 ~ r~t~H ~'' 1~' ~~ ~r, c~ tit-- i 1 ~ 7~ i ~7 ~ ~ _ 1 ~ ~" `~ i _______ TQTAL i Afso enter ~n iine 5 Recapitutat r~~ ` ~ ~ 'i' mrre space ~s needed insert additional she~;ts of the same size ~ ~ ~~