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Home My WebLink About02-06-121505610101 REV-1500 Ex (°1.1°~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes °"""'"`"~° AE°`"°E County Code Year File Number PO BOX 2806oi INHERITANCE TAX RETURN Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ~ ( ~ ~ ~ ~' ~ ~p ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY boo a~ (~~3.5 0~ ~(~ao l t O ~a3 f °Ia7 D~~eppcednnentCCs Last N//am/e~ Suffix Decedent's First Name ~ L t G Z/ (rt (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 m REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate prior to 12-13-82) 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 Numbeny? ~ ` ~ rJ ~ `1 1J 0 S .S" ~ t 7 ~3 ~r,3 ;~` RCbW f (,Ik LS U5'~ ONLY.' - `~i tT1 i •°r'~ First line of address - ; --, ~, , - Second line of address -~ "+ `~ r".°a (':t City or Post Office State ZIP Code DATE FILED ~~ 0 L 1~ P~ I '~1 0 ,2.~ Correspondent's a-mail address: l ~ ll~f ~-G~ ~~~1i ~ ~/~~=Zp~ ~ ~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, correct and complete. Declaration of preparer other than the personal representative is based on all information of which °renarar nac a„~~ 4,,,,,.,io,~,,,. IiLE FOR FILING RETURN __3~~A-~so~~, ~~1~~~4~~P ~~d[~ ~0. r~oas a-y-ia~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ._.._. Side 1 1505610101 1505610101 J J REV-1500 EX Decedent's Name: 1505610105 Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. ~ : - 2. Stocks and Bonds (Schedule B) ..................................... .. 2. _~,r-~ 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. lD ~ 3 g . ~ ~p 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. ~~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested...... .. 7. ~-- 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. - l.S~ ~~-/_ a ,~ 8 • ~o tU 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. L~ I / 9 ~ (~ O i0. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. .------~--- 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 4 q ~ ~ O O 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ ,~ I 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. r 3 f ~ , 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 .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 ~ 3 I ~ , ~ 16. ; 17. Amount of Line 14 taxable ~~ at sibling rate X .12 . 17. ': 18. Amount of Line 14 taxable - - at collateral rate X .15 ~ f+ 18. ~ x i: 19. TAX DUE ....................................................... ..19.E _ . , - ~ ~: 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0 Side 2 1505610105 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: File Number ~oII - o~BJ~ DECEDENT'S NAME ~L~~~ n'1. _~~~~~r~K~./L STREET ADDRESS __-- CITY ~~~~ - __ _ STATE ZIP ~,~ i~oa~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) J I ~ 3a 2. CreditslPayments A. Prior Payments _ _ ____ _ B. Discount -_ Total Credits (A + B) (2) 3. Interest (3) .~- 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. (4) - 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5} SI ~ . 3 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Cid 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 .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 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 "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 tlesignation? ........................................................................................................................ ^ 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, 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+ (11-08) ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER 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. If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) as, - ~ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT wiHit yr FILE NUMBER All property jointly-owned with right of survivorship must be disrtnsad ~~ srho.~ule ~ tir more space is neeaea, insert atltlitional sheets of the same size) REV-1504 EX+ (1-97) . ~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ~-S~ YYl . ~-~ .g~ (L41L- ~o ~ I - 008 ~ ~o Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address City Date of Incorporation State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number 3. Type of Business 4 Product/Seroice Business Reporting Year STOCK TYPE TOTAL NUMBER OF pAR VALUE NUMBER OF SHARES VALUE OF THE VotingiNon-Voting SHARES OUTSTANDING OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining 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 8. Did the decedent sell or transfer an 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 $ Date 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. • • •- • ~ ~ 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. 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 (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 SCFIEDIJLE C-Z PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER __~= c- ~ ll~ - 24~ ~ftl~4.-.2 a d~ 1 - oo S I l~ 1. Name of Partnership Date Business Commenced Address City 2. Federal Employer I.D. Number 3. Type of Business ProducUService Business Reporting Year State Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP 1 BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8 9 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 14. 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 addresses 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+ (1-97) ~~-':'~~~ SCHEDULE D :.:.;~. COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Pt L_~ G~ ~"1 . ~EZ4~ ~Pt-b<4-/L- ~;2 0 (I - 00~ I to All property jointlyowned with right of survivorship must be disclosed on Schedule F lir more space is needed, insert additional sheets of the same size) REV-1508 EX. (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM I VALUE AT DATE NUMBER II DESCRIPTION OF DEATH CPS s H TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) c~ ~ a3 ~. c~c~ s ~,,_~3 ~'. ~ ~, REV-1509 EX t (i-97) SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER ~} ~zc~ try . ~ R4..~~~-~ti,2-- ~ 01 l - 0 0 8 ~ to If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ` ~I~ B. JOINTLY-OWNED PROPERTY: RELATIONSHIP TG DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOIN7 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 DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I $ ~- (If more space is needed, insert additional sheets of the same size) REV-1510 EX ~ (1-W) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEE7 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRRELATIONSHIPTODECEDENTANDTHEDATEOFTRANSFER: ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IFAPPUCASLE TAXABLE VALUE 1. IV TOTAL (Also enter on line 7, Recapitulation) $ ----~-, (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) .~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. v,,~ ~~ L o-- L~~,'n~ T.~o ~ ~P~S~ ~ ~f,q-uL`r B. 1 2 3 4 5 6 7 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State 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 Accountant's Fees Tax Return Preparer's Fees Zip --_ Zip ~, O o'ZO. t:7 0 3pO . a ~ .~~q~a° Sa,oo TOTAL (Also enter on line 9, Recapitulation) I $ ~ G~ I G, p O (If more space is needed, insert additional sheets of the same size) , REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER rceport aedts incurred by the decedent prior to death which remained unpaid as of the date of death. including un~eimnu~eori ,.,o,~~~~~ o.,..e..~„~ to more space is neeaea, msen aaaitional sheets of the same size) REV-1513 EX+ (9-00) SCNEDt~LE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116 (a) {1.2)] ,. C~~`~s ~ k~6f~-K4,2 .~lL. 3 a - (d{ ~~g~~ $R~w,B/{k~2 S o~-.~ 3 a~. q ~ sly T~.,~~« ~~., -,~~ ~~~~~, ~%~ ~ C N4~e-~ ~ u~h141L ~~-a~~+~T oZl~ wyo•~n2~J~ ~~ , ~N~~-~4, Pft ~7no~s 3 ~q . f ~ P~~4'~ Noss ,3 - 7 fl So kTl~t ti~ ~,L.~ ~, ti,,va >_~4, I°f } ~ ~ oat ~~(n ~"(~2- 3 a ~ . ~ ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ -~1~-' (It more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shel ESTATE OF FILE NUMBER A ~--~ cry ~ . ~ 2~ b f+K~/Z ~~ ~ - o 0 81 l~ This schedule is to 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, Specialty Tax Unit. 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 the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS 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 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH • NEAREST AGEAT DATE 4F DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years Value of fund from which annuity is payable ............................................$ ~- 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644 EX ~ (s-oal INHERITANCE TAX SCHEDULE L coM No ER TANCECTAX RETURNANIA REMAINDER PREPAYMENT c~ RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL ~ FILE NUMBER p~ t~ ~ ~ 0 O 6 I. ESTATE OF (Last Name) (First Name) (Middle Initial) 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 principal. II. REMAINDER PREPAYMENT: ~ I ,n ~i~I' A. Election to prepay filed with the Register of Wills on I (Date) B. Name(s) of Life 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 Unincludable Assets .................$ 4. Total from Schedule L-2 ......................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x 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 Annwtant(s) corpus or annuity is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ _ _ (Also enter on Line 7, Recapitulation) ^.C Y-104J CAY ~/-OJ~ INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DE E REMAINDER PREPAYMENT ELECTION ~ ~ ~ ~ r U U~~ C DENT -ASSETS- FILE NUMBER I. Estate of ~ L ZGf_ -~y~ _ 4,,_,~ ,~, 4~~ (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) NIA Total value of real estate $ (include on Section I1, Line C-1 on Schedule L) 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 (attach Schedule C-1 and/or C-2) (please list) 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 It, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Section II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, Line C-b on Schedule L) $ ~~~J (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1646 EX+ (3-84) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN ~Q RESIDENT DECEDENT -CREDITS- FILE NUMBER ~ ~ I I ~ O `~ I I. Estate of l~ 1-y« /Y~ - ~~~~ ~~ ~1--~ (Last Name) (first Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) ~i~ Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total 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. Computation as follows: Total unincludable assets (include on Section I I, Line D-3 on Schedule L) I " III. TOTAL (Also enter on Section II Line D-4 on Schedule L) I $ ~-~ (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDt~LE M FUTURE INTEREST COMPROMISE Box 4a on Rev-1500 Cover ESTATnE OF ,per, I t"' LZ~ m ~ ~ b/ \ P~~ FI aN0 I EI ' 0~ ~ ( lO This Schedule is appropriate only for estates of decedents dying after December 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 which 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 1. 2. 3. 4. TT 5. ~.._ .,___~ III. N • -• ---~~~~~~•~ ~r~~~a ~~~ ~~ a~«~ ~u~y ~, ~~~~+, ~~ a Surviving spouse exercised or intends to exercise a right of withdrawal within 9 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 Explanation of Compromise Offer: summary or compromise otter: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 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 Cover Sheet) 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 Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................~ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) .~~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION ESTATE OF SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) FILE NUMBER X01 I - o dR r l„ i nis 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) ........ M ~~ .............................. 1. 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... g. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: iS a. Spouse ........... ia. b. Decedent .......... 1 b. c. Joint ............. 1c. d. Tax Exempt Income .. Oth I id. e er ncome not listed above ........ 1e. f. Total ............. 1 f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) 2b. 3b. 2c. 3c. 2d. 3d. 2e. 3e. 2f. ~. + (3f) 4b. Average Joint Exemption Income .................................................... . If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit if not, continue to Part 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .................... . 1. 2. Multiply by credit percentage (see instructions) .......................................... . 2. 3. 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 . ............................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. 5. 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....... 5~ REV-1649 EX + (7-97? SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATE OF FILE NUMBER '~ L ~ L4- ~'1 ~ ~24.~.~~P~-~L4--f~ ~ p 1 I - ~ c~~ 1 to 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 a lies to the Trust marital, residual A, B, B -ass, Unified Credit, etc. . If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. 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 similar property 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 arran ement included as a taxable asset on Schedule 0. The denominator is a ual to the total value of the trust or similar arran ement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin spouse under a Section 9113 (A) trust or similar arrangement. ~i~ PART B: Enter the A Total tlr more space is needed, insert additional sheets of the same size) COMrAONWEALI"H OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU Of INDIVIDUAL TAXES DEPT. 280601 HARRISBUFG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX111-961 N0. CD 015552 MOSS PENNEY A 317 A SOUTH ENOLA DR ENOLA, PA 17025 ~-- fold ESTATE INFORMATION: ssN: zoo-22-s~s5 FILE NUMBER: 21 1 1 -081 6 DECEDENT NAME: BREWBAKER ALICE M DATE OF PAYMENT: 02/06/2012 POSTMARK DATE: 02/06/2012 couNTY: CUMBERLAND DATE OF DEATH: 07/ 1 6/201 1 REMARKS: CHECK#164 ACN ASSESSMENT AMOUNT CONTROL NUMBER TOTAL AMOUNT PAID: INITIALS: CJ 559.38 SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS