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Home My WebLink About01-20-12`~+- s.._..I .1505610101 REV-1500 °` c°~_~°' ~ OFFICIAL USE ONLY PA Department of Revenue pennsylvartia Coun Code Year File Number Bureau of Individual Taxes ~"""'"`"~°`"~"~` ty PO BOXz8o6o1 INHERITANCE TAX RETURN ~~~ ~~ ~~~ Harrisburg, PA i~s28-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Sectarity Number Date of Death MMDDYYYY ~ _1 I T~ 0 I ~12~ 1~ I~ Decedent's Last Name Suffix i` k e (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Date of Birth MMDDYYYY ~~ Decedent's First Name MI ae+~ Spouse's First Name MI ~~r~..r-r~-rr-r~ ^ ~® 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) 4. Limited Estate Q _ 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) 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 ~I ~ ~ ~ ev~ ~'3 3 ~ o[~ First line of address Second line of address City or Post Office State Comsspondent's a-mail address: -~ ZIP Code REGISTB~OF WILLS USE ONLY ~ 0 `~ -~ ~ - '.-;~4~ ~~~ - A ? i'~'1 h~,~ ~~~~ GJ ..... ATE FILED ~•,.~ ._,.; ~ig Under penalties of perjury, I declare that I have examined this return, including a mpanying schedules and state ants, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the person re sentative is on all i fo anon f which preparer any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN AT ',,/ ~O/~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE OR161NAL FORM ONLY Side 1 ;L 150561010.1 1505610101 - J ~~ 15Q5.61Q105 i ~. REV 1500 EX DeceKlenPs Soaal security Number oeceaeR-rs tom: i RECAPitTtlLATION 1. .Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonck (Schedule B} ....................................... 2. 3. Ckuely Held Corporation, Partnership or Sole-Proprietorstup (Schedule C} ..... 3. 4. Mor~ages and Notes Receivable (Schedule D) ........................... 4. , 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 8. 7. Inter--\(nr~ Transfers $ M%soellaneous Non-Probate Pmpecty (Schedule G) p Separate Billing Requested........ 7. _ 8. Total Gross Assets (tom -Linen i ~rougtt 7) ........................:.... 8: . 9. Funeral Expenses and Administrative Costs (Schedule H) ...........:....... 9. ~ u 10. Debts of Decedent, Mortgage Liab~ities, and Liens (Schedule I) .............. 10. ~' 11. Total Deductions'{total Lines 9 and 10) .............................:... 11. ~ t ~ ~; 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 GALGULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under sec. 9116 (ax1.2) 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 .t2 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAXI)UE ......................................................... 19. 20. F~L ~t THE OVAL IF YOU ARE REQUES'FiNG A REFUND OF AN OVERPAYMENT Side 2 1505610105 15O561O1D5 O J REV-'~~e 3 Decedent's .Complete Address: File Number ~ Nun s Zo (~ +ur ~ 3~$ c -~ i ~ ST~-~ ~ t ~o I I Tax Rayments and Credits: 1: Tax Due tP~ 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discotxtt 3. Interest 4. ff Line 2 is greater than Line 1 + Line 3, enter U-e difference. This is the OVERPAYMENT. Fill ht oval on Page 2, Line 2Q to request a refund. (1) 2~. ~ $ Total Credits (A + g) (2) ~ (3) (4) 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 7.~g 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 shah use the Property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ I~ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................:................................................................................ ^ 3. Did decedent own an ~n trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement acxount, annuity or other ncn-probate properhr, which contains a benefiaary designation? ........................................................................................................................ ^ THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART ~ THE RETURN. For dates of death on or after Juty 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 [T2 P.S. §9416 (a) (1.1) (i)]. For dates of death on a 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 discbsure of assets and filing a tax rim are stiff applicable even if the surviving spouse is the only benefiaary. For dates of death on or after July 1,2000: • The tax rate imposed. et the net value Of transfers from a deceased child 24 years of age a 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. §9146(a}(1.2}}. • The tax rate imposed on the net. value of transfers to or for the use of the decedents lineal benefiaaries is 4.5 percent, except as rioted in 72 P.S. §9146(4.2)172 P.S. §9416(a~1)}. • The tax rate imposed et the net value of transfers to or for the use of the decedents siblings is-92 percent [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Beefier 9402, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. .r __ REV-1508IX ~ (1~~ CAMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF t ~1.~ SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY FILE NUMBER Indude the prooeds of litigation and t~ date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. ehtcc~-~+~v~ account . t Ih~-T Bates i b Box ~la~~ [3k log N ~~fz~fo- 6~8~ 13 3 07.40 ~ 31 oa~3q 151 y~ Z1 ~t (o .y ~ lanJ~r.~~ of av~n,~,tit -ds ~-~ ~ -f~'"-, and cl~,~ ~ b 1, ~ . ch~c~ {,~Yh~s ~,a.v('-~-Q - r zfi~~--- '' cr~n.ec,~- i~ I'~b <uB TOTAL (Also enter on line 5, Recapitulation) I = ~ ~~ 5 ~3 , ~ O (If more space is needed, insert additional sheets of the same size) „ x COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT i SCNEDVLE N FUNERAL EXPENSES 8~ ADMINISTRATNE COSTS ESTATE OF ITEM A. a. 1 FILE NUMBER Debts of decedent must be reported on Schedule L :R DESCRIPTION FUNERAL XPENS~S: [ _,, /~ ,. _ , _ p _ ~ 1. -~'~U4 $Z~'i/~GtJi"''n'~'~C '~f ~cv~ 5'1~Mt ~(4.1V j:QRnr-..~,Jarne.5 ~~fhu,-~r tJR ~-I ~(a8'('hs-d ~dtiw~Ctt.mhc(~lart~f i'7a~D ~, CorlClnr~G U ~ (~F-~.f~ ~ ~. c+~ a(~ L ~~ D'D z~~o '~a~u ~ ~cl~.~. (e~~P early 5~ 'h~~`~.~''aoo-~~FF~~-- v(Ztt ~CaS~'$e~t~ c1S a~O/t? ~• ~~~wr`f~ewt [~a~uft~,,vt e±-.e.Q.r- C ~ f Ca"", p~ h , Ca~ ~l 'I(I P~ ~- d~G-, $. ~U.n~,r-~.P fisDd tt r.c4n.c~,--, ~It Dt~~ ,wb~~ D~ -f~.eC ADMINISTRATIVE COSTS: °!. fwel-trx~a~cd~{wn~ `~''~'-~~ IT~e~u ~"E'~``•1~~"C°~f'~"' Personal Representative's Commissions It)r ~~ tMI~1 Name of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: __ 2. ~ Attorney Fees 3. I Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address .City State Zip Relationship of Claimant to Decedent 4. ~ Probate Fees 5. I Accountant's Fees 6. ~ Tax Return Preparer's Fees 7 ~~~~.ab Rgs=ao 3G•oo (fo•oo Z~y.ov ~~qs ~ ~a3. W t'[8.6 $ R't•q~ ~-. ~ TOTAL (Also enter on line 9, Recapitulation) I S ~ Q r7 ~S (If more space is needed, insert additional sheets of the same size) • ~ EX+ (12-03) SCMEpuLE 1 b ~ COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE F g~ FILE NUMBER ~~ ~.f L ~ Repo ebts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE ,. ~Pt- Ae~~~A~l~fiesi~fawa-~,~~~ 1~-~l 2-$l•2Z 2. Tvuy}• ~~4/hCel II ~I~v-~'-robc~v~ •~~'"~ ~ti (I I P~ I~al t 1 Zo. o c~ 3, .1-~4cf.~,t~~ of c~e+~-E~.P P1~ t c~$ lol-ns-r ~i~- i Ge (hie, ~ I ~o ~ 3 ~ h.>~d~e t ~ 2. ~a ~". Bair ~•~hbbs~ J~rnlot,~,l arse I t 0 6t1k ~{ 7, fin, o(,a (~k ha u ~g • a ~ ~ - IBS Ca~.P -fit III N~`^~, nob Ihu.~.t.-F-~- • ~ C.a~+t ~I(i (a'~ h~tt -~~ ~ o . a ~ ~, 1M~S-I' S~.o~e ~(hSl ~~ ~-~~Q ~,e ~ 2~1(-~.~ ~fl~k~~.~.~c ~~ r TOTAL (Also enter on line 10, Recapitulation) S 17~S , ~~ (If more space is needed, insert additional sheets of the same size)