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HomeMy WebLinkAbout02-21-1215D5610101 1 Ex rol-io) REV- i ~OO OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes ~"",."`r.o."`~`~u` County Code Year File Number PO Box s8o6oi INHERITANCE TAX RETURN ,~ d ~ y Harrisburg PA 1'7128-o6oi RESIDENT DECEDENT _ ~ ~ ~ 'J ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY vSa`~'aoag ©S~b~©o'~ Decedent's Last Name Suffix Decedents First Name MI '~'oN~ s o1Q CHAs~ 14 (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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) ~ 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required 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 TO: Name Daytime Telephone Number l-I i C N g E t, ~ N R v r e S k y ~~ ~ S ~! l 9~ a S First line of address 02 D ~{ a L i N (,- L O S T O tv N Second line of address $ u i T c 3 0 3 City or Post Office I~ A ~. ~ i S~ u Q b~ ~, D ~ (~ State ZIP Code A l 7 I Correspondent's a-mail address: hll~lAlhT~k-/ ~_ No l.!) t.c.~t CO REGISTER OF WILLS USE ONLY C7 h..e ~, ~ ` ~t-# ~ -> ri ~ tom' C7CJ ~ , z; `~ ~ rT7 N ~. ~ ~ - t E FILED -" = -T; ' " ~ ry r-i j D s- -~' 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 preparer has any knowledge. SIGNATU OF ERS ONySI E OR FILING RETURN DATE a-/s- ~a. ADDRESS Su i ~ ~~ 0200 ~ Iv6i.~ow ~~~ , 1~~4~2isat.tP~-, #i t7c~a SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 REV-1500 EX Decedent's Name: RECAPITULATION 1. Real Estate (Schedule A) ............................................. L D f o p 2. Stocks and Bonds (Schedule B) ....................................... 2. D • O ,~ 3. Closel Held Co ration, Partnershi or Sole-Pro rietorshi Schedule C Y ~ P P P( ) ..... 3. Z~ p 0 ~, 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. O ~ D G 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ ~ ~ -:. 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. Q ~ O . ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ ~ ; `~"-# X>' ° 1 ' (Schedule G) p Separate Billing Requested........ 7. O ~ O , O 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ .~ d O 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. O * D ~ O 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ,~ ~ p ,, ~ 11. Total Deductions (total Lines 9 and 10) ................................. 11. D ,~ fl , D 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. D ~ O .D 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which '-±?rt;±~~e:~~~ ~~t~:,.~~~~;~ =,~•.:- ~ i an election to tax has not been made (Schedule J) .......:...:..... , ....... 13. ~ O ~; O f O . ,~. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. t~ ~ Q Q TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~* ,_- *~ rr ,~~~ ^ fir....,.,. __ - ~ _ ~- ~ (a)(1.2) X .0_ ~ '~.~ ~~ 15 _ ~ ~_ 16. Amount of Line 14 taxable - ~ ~ ~` ~ F r 3~ at lineal rate X .0 _ ~ a ~ r ~ Z 16. ; ~ ~ ~ ~ ~ ~ ~ D ~~ 17. Amount of Line 14 taxable '' "'{"' '"'"'~' '~'-' r ~`..~ ~,k at sibling rate X .12 18. Amount of Line 14 taxable ~ ~'''{ ~~~ `~"'~ at collateral rate X .15 17. 18. 19. TAX DUE ...................................:.......:............. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p 1505610105 Decedent's Social Security Number Side 2 L 1505610105 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME STREET ADDRESS - -- ----- CITY STATE T ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) ~ Total Credits (A + B) (2) Q (4) (3) ~ (5) Make check payable to: REGISTER OF WILLS, AGENT. _. ~ . , PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS D 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 : ...................................... ...... ^ X^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ 0 d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ Q 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 0 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 designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART O_F THE RETURN. : .. wY- - A~'9: T''~. '-. 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. D