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Home My WebLink About01-18-12J 1505610101 OFFICIAL USE ONLY PA Department of Revenue P~~Ylvartia Bureau of Individual Taxes ~NEVENIIE County~Code Year File Num~'b~e',r'--~''~ Po Box s8o6o~ INHERITANCE TAX RETURN E'~i t 1 I ~ 11~ ~ ~N~ 1-1'1 Harrisburo. PA i~128-0601 RESIDENT DECEDENT ~, REV-1500 °` t°~_1°' ~ Date of Birth MMDDYYYY e ~ a ~'l~T~'f~'~1 Decedent's First Name tt MI Spouse's First Name MI r~r-rrrr~r~m-r1 - ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~~~~ ~ REGISTER OF WILLS FILL INAPPROPRIATE 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 (Attach Copy of Will) O 9. Litigation Proceeds Received O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Da me Te yti lephone Number REGIST~ ~ WILLS USE.ONLY 'C3 First line of address ~~- ~ ""' ~ v. ; ti, / 1 „ +, ...3 "~ Second line of address ..~ -1 .. ,...._ City or Post Office State ZIP Co de DATE FILED ~°' / ( Y / 7 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 We, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF P N RESPONSIBLE OR FILIN RETU DATE " l D ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 JAI ~6 J REV 1500 EX DeoedenYs Name: Decedent's Social Security Number RECAPnuuTloN 1. Real Estate (Sdtedule A) ............................................. L y' ~ _.. 2. Stocks and Bonds {Schedule B) ....................................... 2. ~7 3. Closely Held Corporation. Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~ Qfi 4. Mortgages and Notes Receivable (Sc~redule D) ........................... 4. ' j ~~, (. 5. Cash, Bank Deposits and Miscellaneous Personal Property {Schedule E)....... 5. ;} ~" ': 6. Jointly Owned Property (ScdreduNa F) O Separate &I~ng Requested ....... 6. 7 I D . nter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Biting Requested........ 7. '3 ~, 8. Tota! Gross Assets (total Lines 1 through 7) ............................. 8. 4) 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. !, 10. Debts of Decedent, Mortgage Liabilities, and Liens {Schedule I) .............. 10. Q Q D 11. Total Deduction (total Lines 9 and 10) ..........:...................... 11. 12. Net Value of Estats {Line 8 minus Line 11) .............................. 12. 13 Ch ri bl 9 . a ta e and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. Q ~ 14. Net Valus Subject to Tax (Line 12 minus Line 13) ........................ 14. - ts? pG a .r._.-...w. - v~~ nw..wv+.vnv rvn'vr~~a.no~c rcr~~ ca 15. Amount of Line 14 taxable at the spousal tax rate, or t f d S 9116 rans ers un er ec. (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 1 g, 17. Amount of L"me 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 1 g, 19. TAX DUE ..................................................... .... 19. 20. FILL 1N THE OYAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 150561D105 1505610105 1505610105 O s~ REV-1511 EX+ (iQ-O6) ., COMMONWEALTH OF PENNSYLVANIA tNHERiTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. 1 ADMINISTRATIVE COSTS: Personal RepresenlatiVe's Commissions Name of Personal Representatives} Street Address _ - Ciiy Staff Year(s) Commission Paid: 2. 3. 4. 5. 6. 7. Attorney Fees 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 Probate Fees Accountants Fees Tax Return Preparer's Fees Tip Tip TOTAL (Also enter on tine S, Recapitulat+on} I ~ ~~,~~ (1f nare space e; needed, msert additional sheets of the same size) REV-1500 EX page 3 De+cede~t's Complete Address: File Number DECf~ENTS NAME r ____., LE 1 W lJ l~ L ~ STREETADDRE '-- ~ c ~ C CITY ~~~ Pry . STATE Z11 7 ~ ~ Tax Payments and Credits 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prig Payments B. Discount 3. Interest 4. If Lie 2 is greater than Line i + Line 3, enter the dif~enoe. This is the OVERPAYMENT. Fitt al oval on Page 2, Lyle 20 to request a refund. (1) Total Credits (A + B) (2) (3) (4) 5. ff Line 1 + Line 3 is greater than Line 2, enter the diXerence. This is the TAX DUE. (5) 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 shop use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or' .......................................................................................................................... ^ .® d. receive the promise for Iffe of either payments, benefits or care? ...................................................................... ^ 2. If death oaxlrred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................. ............................................................. ^ 3. Did 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 retirerr~nt account, annuity or other non-probate property, which contains a benefiaary desig-aatron? ........................................................................................................................ ^ rr~~ L~ IF THE ANSYI~R 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 des#es of death on or aRer Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 pen~nt [72 P.S. §9116 (a) (1.1) (ii)j. The statute does not exep# a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and Bing a tax return are stiN applicable even if the survivirg spouse is the only beneficiary. For dates of death on or after July 1,2000: • The thx 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 adopfire 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 benefiaaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. 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 Sect+on 9102, as an irxiividual who has at least one parent in common with the decedent, whether by blood or adoption.