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HomeMy WebLinkAbout11-07-11 (2) 1505610101 REV-1500 ~ ~O1.1°' '~ OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Pennsylvania OfP~fTMEHT OF NfVFNUE County Code Year File Number INHERITANCE TAX RETURN PO BOX 28o6oi Harrisburg PA 1'7128-o6oi - RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY .` 5 ~ ~,:~2 ~. O~ 5 ~~~ t ~,,~ 2 -_ N ~ ~ . ~.~ 3 ~~ a ~ ~7 _~ 322 , t ' , a-: Decedent's Last Name y .. Suffix Decedents 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 ' ~ ~D ~3 ~ ..~~ REGISTER OF WILLS FILL tN 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) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 T0: Name Daytime Telephone Number T ~r~~~~~1f ~: L~~}1~ 1 ~s . ,~~ 7 ~l `1 2~3 °~~ 3 I :3 ~ ~ First line of address Second Ilne of address { S'T ~~ City or Post Office F ~~o ~ T s State ~~ REGISTER WILLS USE ONLY .- Q - `~`-- _. ~~.i ~ Ca ~ r:' :rte r- "~:: ~~-_ ~»x ~~~}~~, :J C ~ _ ~, ~, DATE FILED _. ~"', r_... ZIP C~o]de ~ t ~~}-2. ~~ ;, ~c7 -: r ~. Correspondent's a-mail address: 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 o er has any knowledge. SIGNATURE OF PERSON, RESPONSIBLE FORS ING RE~RN~ d DAB / C '~ ADDRE r 3/~i ~/~Q [~./ [~/~i/ 9 "'''~//I ~s~ %/1 /70D~ ~riir+~/ SIGNA~U OF B E6t OTHER THA REPRESENTATIVE DATE ~ ~ ADDRES)sfo/ /Vf 1r7N1/.~3/r/ /~/ ~/f ~/y7f) ~/~ ~//D~ /~ PL E USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J REV-1500 EX Decedent's Name: RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. a _.... , . 2. Stocks and Bonds (Schedule B) ....................................... 2.~ 3. Ckuely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E}....... 5. 6. Jointly Owned Property (Schedule F} p Separate Billing Requested ....... 6. 7. Inter-Vrvos Transfers 8~ Miscetlaneous Non-Probate Property (Schedule G) p Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 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 s usal tax rate, or transfers under ec. 9116 ~~ _ + _~°,~ (a)(1.2) X .0_ k ~ ~ ~ Q 15. _ ' "" ~~ " 16. Amount of Line 14 taxable ~ :_ ~ at lineal rate X .0 _ ~ 16. 17. Amount of Line 14 taxable "~ ~ ~.~:r2` ~'y, at sibling rate X .12 ~ 17, 18. Amount of Line 14 taxable ~~~ ,~~~~~' - r at collateral rate X .15 _ ~ s 18. 13. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610105 Decedent's Social Security Number O Side 2 1505610105 1505610105 File Number Tax Payments and Credits: 1. Tax Due (Page 2, Line 19} 2. Creditslpayments A. Prior Payments -- B. Discount 3. Interest 4. If l.irie 2 is 9~ ~t~n oval on ~ 2, Lme ~ o request a refundthe OVERPAYMENT 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) D Total Credits (A+ B } (2) (3} (4} (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPR{ATE BLOCKS Yes No 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :............ . b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .................................. d. receive the promise for life of either paymena ,nbernae s eoarope~ within one year of death ^ 2. If death occurred after Dec. 12,1982, did dece without receiving adequate consideration? ............................................................................................................ ^ 3. Did decedent own an "in trust for" ar 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. 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, t~xem aetransfe to a surviving spouse from tax, and the statutory requ cements fond sclosure of assetsand [72 P.S. §9116 (a) (1.1) (ii}). The statute does no p filing a tax return are still applicable even if the surviving spouse is the onty benefiaary. For dates of death on or after July 1, 2000: rat death to or for the use of a natural parent,. an • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younge adoptive parent or a stepparent of the child is 0 percent [72 P.S. §g116(a)(1.2)]. The tax rate imposed on the net lvalue of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)( )] • The tax rate imposed on the net valh oat eastt oneo aorent m common witl~ the deecedent, nwhether by blood or adoptwn116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who P REV-1500 EX Page 3 Decedent's Complete Address: REV-1502 EX+ (O1-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN aFStDENT DECEDENT SCHEDULE A REAL ESTATE FILE NUMBER: ESTATE OF:/~vI Iv I ~ ~~ G - // All real property Owned solely or as a tees and a willingosel e~rsn b heebeirtgaompelled torbuy oaseell, both having relasonablelknowledge of the re evlant Pacpts.~ that is ointl owned with rt ht of survivorship must be disclosed on Schedule . would be exchanged betwe Real prloperty ] Y' 9 Attach a copy of the settlement sheet if the property has been sold. VALUE AT DATE ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. OF DEATH NUMBER DESCRIPTION ~. r ~ R~i~in - .S >>n s p~ 1~~07 ~.IZ~100o 3©~ ~ :9 ~~~ ~y ~ 9 ~ Ca ~ i s~~ I a~~j P~ TOTAL (Also enter on Line 1, Recapitulation.) $ 1 ~ ~IJ~ If more space is needed, use additional sheets of paper of the same size. REV-i5o8 EX+ (11-io) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN ~~cm~nir nFf FIIFNT SCNEDI~LE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE ITEM YI )C~;ril.S~l Include the proceeds of litigation and the date the proceeds were received by the estate All property jointly owned with right of survivorship must be disclosed on Schedule F. U1ar,~O~~0. Bwkf~ ~165-N~o~Z~oB~ Csn!en~-q~ar~~) ~~~5 hard Ua~ ~/` II/~,~ Cr'oP~ ~"~}le Cet~17u+~P A71u"""'/ VALUE AT DATE OF DEATH / `~~ TOTAL (Also enter on Line 5, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. FILE NUMBER: ~.~I~ -l1 S REV-1510 EX+ (08-09) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFE~tS AND MISC. NON-PROBATE PF~OPERTY oFCrnENT DECEDENT I ILE NUMBER ESTATE M ,Q, F This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) UMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. ~. ~i~on ~~z ~a`(~~~~~a~~e ~OD9'0~'Drl a~ ~~ ~e~e~~ ~D~ Doi II5 feM~u~ ,~e~U ~J P 2 a~~~J Cs~ TAXABLE TOTAL (Also enter on Line 7, Recapitulation) $ 3 Q ~ I If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE ~~ I ~ ~, ~ ~ ~ ~~ ITEM NUMBER A, FUNERAL EXPENSES: 1. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER Decedent's debts must be reported on Schedule I. g, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address State ZIP ------ City Year(s) Commission Paid: _ Z, .Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant ____-- Street Address _ State ZIP ---- City Relationship of Claimant to Decede/nt 4, Probate Fees: ~ ~ / ~~ a~~~ ) ~I~i~~~~P.ZS lll... ~_ 5. Accountant Fees: 6, Tax Return Preparer Fees: 7. 3 ~~'' TOTAL (Also enter on Line 9, Recapitulation) $ ~ Z`1`~ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) SCHEDULE I ~ Pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES $c LIENS RESIDENT DECEDENT FILE NUMBER 1 ESTATE 0 ,, f i ~~ ~ ~ "" ~c, T, -l, Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medicOF DEATHe VALUE AT DATE ITEM DESCRIPTION ' Ulells f~r9o ma e~~ ~ Iav- ~) I~e ~ Fc~cx~~~ ~S~u~+mert~ d~°~ ~fa~ ea~~ 2913 ~'~ g3; x-6'7 2319'aS TOTAL (Also enter on Line 10, Recapitulation) $ I 0 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (O1-10) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN ___-_-..T ncrcnGNT SCHEDULE 7 BENEFICIARIES ESTATE OF: n~ L5 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY NUMBER I TAXABLE DISTRIBUTIONS [IncluSe o 9116t(a) (ls2) ;istributions and transfers un er 1. RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBE ~~~ ZI- D- AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS DER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. aces ~ ~ ~~ ~sl~l B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. 10a~os~ TOTAL OF PART II ENTER TOTAL NON TAXABLE DISTRIBt~TonONS ONs ofNpaper of the sam5e oiZ OVER SHEET. $ If more space is needed, use add