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HomeMy WebLinkAbout11-09-11 (2)' ~ 1505610140 REV-1500 Ex ~°'-'°' OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN ~ ~ ~ ~ ~ j ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT / ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 9 3 3 8 0 9 6 2 1 1 0 2 2 0 1 0 0 3 1 1 1 9 5 0 Decedent's Last Name Suffix Decedent's First Name MI F r a n c i s I I I J o h n M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Q 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 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 J a k e F r anci s 7 1 7 7 3 2 1 9 6 0 First line of address 5 6 0 Val l e y Second line of address City Or Post Office S u m m e r d a l e Correspondent's a-mail address: S t r e e t State PA ZIP Code REGISTER aF WILLS USE`QNLY -,~ _._ y ;.~ ~ '. _5, ~ ~ -=...;= I ~r~n ~. v', ~__ . ~(w3_r'7 ,-~ . j _-r __._.I C_~ - - ~TE FILED ~~ ~ 1 7 0 9 3 C 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, co and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATUR O ERSON RESP E FOR FIL RETURN DATE 56Q Valley Street ~ Summerdale PA 17093 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 .~ 1505610240 REV-1500 EX Decedent's Social Security Number John M. Francis, III 1 9 3 3 8 0 9 6 2 Decedent's Name: RECAPITULATION 1. Real Estate Schedule A 1. 7 5 0 0 0. 0 0 2. Stocks and Bonds (Schedule B) ............................... ..... .. 2. 3. Closely 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. 1 8 8 9 9 • 9 8 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous N Probate Property ~ (Schedule G) Separate Billing Requested . .... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ..................... .... .. 8. 9 3 8 9 9 • 9 8 9. Funeral Expenses and Administrative Costs (Schedule H) ............ .... .. 9. 8 2 6 1 1 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 8 2 6 9 7 • 9 2 11. Total Deductions (total Lines 9 and 10) ......................... .... .. 11. 9 0 9 5 9. 1 1 12. Net Value of Estate (Line 8 minus Line 11) ...................... .... .. 12. 2 9 4 0. 8 7 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. 2 9 4 0. 8 7 TAX CALCULATION -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 .o _ 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 2 9 0 4. 8 7 16. 1 3 0. 7 2 17. Amount of Line 14 taxable 0 0 0 0 0 0 at sibling rate X .12 17. . 18. Amount of Line 14 taxable 0 0 0 ~ ~ 0 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 1505610240 1505610240 1 3 0.7 2 ^ REV-1500 EX Page 3 Decedent's Complete Address: File Number 0 0 DECE'~ENTS NAME John M. Francis, III STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: Tax Due (Page 2, Line 19) Credits/Payments A. Prior Payments B. Discount Interest 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. (1) 130.72 Total Credits (A + B) (2) (3) 0.00 (4) 0.00 If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 130.72 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 income; .......................... : .... ^ c. retain a reversionary interest; or ........................................................................................... ..... ^ ^X 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 without receiving adequate consideration? .................................................................................. ..... ^ 0 3. Did decedent own an "in trust for" orpayable-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 i 3 percent [72 P.S. §9116 (a) (1.1) (i)J. Fortdates 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)]. 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)]. • 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. REV-1502 EX~ (01-10) pannsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER: John M. Francis, III 0 0 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION Valley Road, Summerdale, PA -Appraised value 75,000.00 TOTAL (Also enter on Line 1, Recapitulation.) ~ 5 SCHEDULE A REAL ESTATE If more space is needed, use additional sheets of paper of the same size. REV-1503 EX ± (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER John M. Francis III 0 0 All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 2, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1504 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER John M. Francis, III 0 0 Schedule C-1 or C-2 (including all supporting infonnation) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) REV.- i 505 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER John M. Francis, III 0 0 1. Name of Corporation State of Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business Product/Service 4. Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? .............................. ......... ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? .............................. ......... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy ___ __. __ 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ............ ^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ................................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ....................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ...................... ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. Date A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Votin n-Voti SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENTS STOCK (If more space is needed, insert additional sheets of the same size) REV-1506 EX, < (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT -- ESTATE OF FILE NUMBER John M. Francis, III 0 0 Name of Partnership Date Business Commenced Address Business Reporting Year City State Zip Code Federal Employer I.D. Number Type of Business Product/Service Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPRAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ Was the Partnership indebted to the decedent? ................................ ^ Yes ^ No If yes, provide amount of indebtedness $ Was there life insurance payable to the partnership upon the death of the decedent? ........ ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death?........ ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................. ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? ................................ ^ Yes ^ No If yes, explain Did the partnership have an interest in other corporations or partnerships? ................. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX + (6-98) - ~ SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES ~ NOTES IN REST DENTEDECEDENTRN RECEIVABLE ESTATE OF FILE NUMBER John M. Francis III 0 0 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 4, Recapitulation)I S 0.00 (If more space is needed, insert additional sheets of the same size) REV-1508 EX,r (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER John M. Francis, III 0 0 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. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sovereign Bank#140469272-Estate checking account 18,899.98 TOTAL (Also enter on line 5, Recapitulation) ~ 5 1 g 899 gg (If more space is needed, insert additional sheets of the same size) REV-1509 E}+ (01-10) . ~ Pennsylvania DEPARTMENT OP REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY is ~ A ~ t oF: FILE NUMBER: John M. Francis III 0 0 ff an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A . . 0.00 TOTAL (Also enter on Line 6, Recapitulation) I S 0 00 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (OS-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY FILE NUMBER John M. Francis, III 0 0 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IFAPPLICABLE) TAXABLE VALUE 1. TOTAL (Also enter on Line 7, Recapitulation) 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 SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER John M. Francis III 0 0 Decedent's debts must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home 5,572.00 Cumberland Law Journal-Advertising 75.00 The Sentinel 240.19 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2, Attorney Fees: Karl E. Rominger 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant 4 Street Address City State ZIP Relationship of Claimant to Decedent Probate Fees: Cumberland County Register of Wills 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. 2,000.00 374.00 TOTAL (Also enter on Line 9, Recapitulation) I S If more space is needed, use additional sheets of paper of the same size. REV;1512 EX+ (12-OS) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER John M. Francis ill 0 0 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PPL Electric 1,014.95 Quantum Imaging 23.57 PA Gastroentology 78.10 West Shore EMS 161.99 East Penn Ambulance ~ 108.75 Holy Spirit Hospital 1,316.54 US Treasury 3,250.00 American Water 131.26 Condo Fee 120.00 Vehicle Registration 36.00 Azizkhan Internal Medicine 451.76 Sovereign Account#0176682341-Mortgage 29,767.00 Sovereign Account#4529808025-Home Equity Line of Credit 46,238.00 TOTAL (Also enter on Line 10, Recapitulation) ~ S If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (U'I-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: John M. Francis III 0 0 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).J 1. John M. Francis, IV Lineal 100.00 II. 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I S more space is needed, use additional sheets of paper of the same size. REV-1514 EX+ (4-09) pennsylvania ' DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box 260601 Harrisburg PA 17128-0601 SCHEDULE K LIFE ESTATE, ANNUITY ~ TERM CERTAIN (CHECK BOX 4 ON REV-1500 COVER SHEET) ESTATE OF FILE NUMBER John M. Francis III 0 0 This schedule should be used for all single-life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME OF LIFE TENANT DATE OF BIRTH... NEAREST AGE AT DATE QF DEATH TERN OF YEARS LIFE ESTATE tS PAYABLE ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years 1 Value of fund from which life estate is payable .. . ...................................... $ 2. Actuarial factor per appropriate table . . ............................................. . Interest table rate - ^3.5% ^ 6% ^ 10% ^Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) . . . ................................... $ NAME ©F LIFE ANNUtTAN7 DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERN OF YEARS ANNUfTY IS PAYABLE ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years 1. Value of fund from which annuity is payable . ......................................... S 2. Check appropriate block below and enter corresponding number . ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Seml-annually (Z) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ...................................................... S 4, Aggregate annual payment, Line 2 multiplied by Line 3 . ................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6% ^ 10% ^Variable Rate 6. Adjustment Factor (See instructions) ............................................... . 7. Value of annuity - If using 3.5%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ...........................S If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Line 5 x Line 6) + Line 3 ................................................. S _ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. REV-1644 EX+ (01-10) I. pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST CORPUS ESTATE of FILE NUMBER Francis, John M., III 0 0 This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on (Date) B. Name(s) of L+fe Tenant(s) Date of Birth Age on date Term of Years Income or Annuitant(s) of Election or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ......................... $ 3. Closely Held Stock/Partnership ............... $ 4. Mortgages and Notes ....................... $ 5. Cash/Misc. Personal Property ................ $ 6. Total from Schedule L-1 .................... ................ .............. ..$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities .......................... $ 2. Unpaid Bequests .......................... $ 3. Value of Non Includable Assets ............... $ 4. Total from Schedule L-2 .................... ................ .............. ..$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) ............... .............. .. $ F. Remainder Factor ........................... ................ .............. .. G. Taxable Remainder Value (Multiply Line E by Line F) .............. .............. .. $ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed ........................... ................ .............. ..$ D. Remainder Factor ........................... ................ ............... . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) ........ ............... . $ (Also enter on Line 7, Recapitulation) REV-164 EX+ (11-09) INHERITANCE TAX Pennsylvania SCHEDULE L-1 ' DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT 'ASSETS' I. ESTATE OF FILE NUMBER Francis, John M., III 0 0 II. ITEM NO. DESCRIPTION VALUE A. Real Estate (Please describe.) Total Value of Real Estate (Include on Section II, Line C-1 on Schedule B. Stocks and Bonds (Please list.) Total Value of Stocks and Bonds $ (Include on Section II, Line C-2 on Schedule L.) C. Closely Held Stock/Partnership -Please list. (Attach Schedule C-1 and/or C-2.) Total Value of Closely Held/Partnership $ (Include on Section II, Line C-3 on Schedule L.) D. Mortgages and Notes (Please list.) Total Value of Mortgages and Notes $ (Include on Section II, Line C-4 on Schedule L.) E. Cash and Miscellaneous Personal Property (Please list.) Total Value of Cash/Miscellaneous Personal Property $ (Include on Section II. Line C-5 on Schedule L. III. I TOTAL (Also enter on Section II, Line C-6 on Schedule L.) ~ $ If more space is needed, attach additional sheets of paper of the same size. REV •.646 EX+ (17-09) Pennsylvania INHERITANCE TAX ' DEPARTMENT OF REVENUE SCHEDULE L-2 INHERITANCE TAX RETURN RESIDENT DECEDENT REMAINDER PREPAYMENT ELECTION -CREDITS- I. ESTATE OF FILE NUMBER Francis, John M., III 0 0 II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Liabilities $ (include on Section 11, Line D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Schedule L-1 {please list) Totat Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Assets Reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV-1647 EX+(02-10j p~nnsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE {Check Box 4a on REV-1500) ESTATE OF FILE NUMBER John M._Francis, III 0 0 This schedule is appropriate only for estates of decedents who died after Dec.12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY ~. 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest .................................................. $ 2. Value of Line 1 exempt ftom tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) ...... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. [] 6%, ^ 3%, ^ 0% ................ $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. [] 6%, ^ 4.5% ...................... $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 ofREV-1500.) ...... $ 6. Value of Line 1 taxable at collateral rate (15°!°) (Also include as part of total shown on Line 18 ofREV-1500.) ...... $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ..................... $ If more space is needed, use additional sheets of paper of the same size. REV-1648 EX~02-09) SCHEDULE N 'pennsylvania DEPARTMENT OF REVENUE SPOUSAL POVERTY CREDIT • Bureau of Individual Taxes PO Box 280601 FOR DATES OF DEATH 01/01/92 TO 12/31/94 ESTATE OF FILE NUMBER John M. Francis, III 0 0 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. • • -• 1. Taxable assets total from Line 8 (cover sheet) ...................................................................................... 1 ~ 93.899.98 6a. Other nontaxable assets: List and attach schedule if necessary .. 6 b. 6 c. 6. SUBTOTAL (Lines 6a, b, c, d) .............................................................................................................. 6. 7. Total gross assets (Add Lines 1 thru 6) ................................................................................................ ~~ 93 899.98 8. Total actual liabilities ............................................................................................................................ 8. 9. Net value of estate (Subtract Line 8 from Line 7) .................................................................................. 9. 93 899 98 If Line 9 is greater than $200, 000 -STOP. The estate is not eligible to claim the credit. /f not, continue to Part !!. Income: ~ ~ ~ ~^ i ~„R• ~ ~ L. IAA T tAK: 7 `J 3. TAX YEAR: 79 a. Spouse ............................. 1 a. 2a. 3a. b. Decedent ......................... 1 b. 2b. 3b. c. Joint ................................. 1 c. 2c. 3c. d. Tax-exempt Income ......... 1d. 2d. 3d. e. Other income not listed above ..................... te. 2e. 3e. f. Total ................................. 1f. 2f. 3f. 4. Average joint exemption income calculation 4a. Add joint exemption income from above: (1f) + (2f) + (3f) - (=3) 4b. Average joint exemption income .................................................... ........................................................... If line 4(b) is greater then $40,000 -STOP. The estate is not eligible to claim the credit. if not, continue to Part III. Insert amount of taxable transfers to spouse or $100,000, whichever is less .......................................... Multiply by credit percentage (see instructions) ....................................................................................... This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet ................................................................ For nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate .......................................................................................................................... Multiply Line 3 by Line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet ......,... REV-1649 EX-} (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER John M. Francis. III 0 0 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital residual A 6 BY-pass Unified Credit etc If a trust or similar arrangement meets the regwrements of Section 9113(A), and: The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilarproperty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. Description Value Part A Total $ Part B: Enter the descri tion and value of all interests included in Part A for which the Section 91 13 A election to tax is bein made. Description Value Part B Total (If more space is needed, insert additional sheets of the same size ) • REV-1500 Discount, Interest and Penalty Worksheet .- Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: Discount: 0.00 Interest Table Year Days Delinquent this time period Balance Due Interest this year this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throw h 1991 1992 1993 throw h 1994 1995 throw h 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: