HomeMy WebLinkAbout10-21-11'J
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 2Em601
Harrisburg, PA 17128-0601
15056051047
OFFICIAL USE ONLY
Counri Code Year File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Date of Birth
Suffix Decedent's First Name MI
R t~~r~4riy~y~i~~~~ ri
Sufftx Spouse's First Name MI
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
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) ~ -
r•_
O
9. Litigation Proceeds Received
O
10. Spousal Poverty Credit (date of death _
O 11. Electio4~ tax under S~ 9113 .
between 12-31-91 and 1-1-95) (Attach~~b)
Spouse's Social Security Number
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAT~1~ BE
Name Daytime Tele ber
D Pl ~ L_BER f~ 7 / 7 `~
Finn Name flf Aoolicable) _ _ __--. ~--
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Correspondent's e-mail address: ~NE t
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.
OF
RETURN
I
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
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Side 1
15056D51047
15056051047 J
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T1
REV-1500 EX
Decedent's Name:
Decedent's Social Security Number
RECAPITULATION
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1. Real estate (Schedule A) .......................................... ... 1.
2. Stocks and Bonds (Schedule 6) .................................... ... 2 t,i
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. o
4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4.
5.
Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .....
... 5. p
"/
6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested..... ... 7.
8. Total Gross Assets (total lines 1-7) ................................. ... 8. 9 jt
9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~ I 8
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10.
11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 7 9 a
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12 "' ~ 1 d b l.7
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13. x ~ 1
14. Net Value Subject to lax (Line 12 minus Line 13) ................... ..... 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 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 .15 18.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 15056052048 15056052048
15056052048 r ~ .
O
REV-1500 EX Page 3 Flie Number
~et:~den~s Complete Address:
DECEDENT'S E
_ ~~w-1~~~a n! - G~ l b_ Lam?"
STREETA~RE~~ ~XBu~y ~ ),
CITY ~~~~/ `'
STATE n^ ZIP ~~
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Tax Payments and Credits:
(1)
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D + E )
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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
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 Vansfer and: Yes No
a. retain the use or income of the property transferced :.................................................................................... ...... ^
b. retain the right to designate who shall use the property transferted or its income : ...................................... ...... ^
c. retain a reversionary interest; or .................................................................................................................... ...... ^
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
^ ~,f
without receiving adequate consideration? ........................................................................................................ ...... L~
3. Did decedent own en "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 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.
aEV-iwa a. uan
' SCHEDULE E
` COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, 8 MISC.
INHERITANCE TAX RETURN PEpS~NAL Pp~PEp 1 I
RESIDENT DECEDENT GRR~7 M r 1lll GRR 1
ESTATE OF ll FILE NUMBER
Indude the proceeds of litigation and the date the proceeds were received by the eshate. All property joirdy-0vmed with the right of survivorship must be disebsed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 5, Recapitulation) I S ~ 93 ~ , G~
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
SCNEpULE M
* COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c
INHERITANCE TAX RETURN ADMINISTRATNE COSTS
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule L
ITEM
NUMBER
A. FUNERAL EXPENSES:
t.
B. ADMINISTRATIVE COSTS:
~. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City
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
TOTAL (Also enter on line 9, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size)
Zip
State
Zip
`7~ X33 . °i°
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901.00
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