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HomeMy WebLinkAbout02-16-121505610101 J REV-1500 ex `°1.1°' ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN ~ ~ Q ~ 7 ~ Harrisburg PA 1']128 0601 ~ ! RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~~(,, ~o \~loS ~2j coo > > %~ kl q l ~i Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ~ b~ ~~r o~~ ~~ R Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ ~ ~ \ ~ C ~ ~ ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) ~ 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 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 TO: Name Daytime Telephone Number y REGISTER OF WILLS US~NLY _ TJ _r -~~ rt ~ t> First line of address ~ n ~ C7 CJO <. ~ u~ ~ _ -- Second line of address ~ f7r~ -~+ `'gyp-„ ~ _ ~ ZIP C St t d DAT~ILED ,7Y~ City or Post Office e a e o y,,,,,. C.'"1 ,~7 I P V' ~. ~ ~ b ~ (~ C~ "~ C ~~ ~ ~ I ~ J ~ ~w~ Correspondent's a-mail address: ~ l`S ~ 2 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. SIGN~IRE ~P^RSC~ ~ES'PONSIBL~OR FI~,IA~G TU ~ ~ DATE ADDRESS 7 I 1 ~ 7 ~ (~/ nn .. _ / ,_.-r /i%F. ~, lA C> \~;:7/7nn,c G]~.riYC + A 170[57 SIGNA RE P P RER OTHE AN REPRESENTATIVE ""' ~ / -~. a-~=y-~= .f-' ADDRESS lG/~" i ~~v ~~l 20 S~ ~~ne~Y~s ~~g , /`~,~- i 7 ~ s ~ PLEASE USE ORIGINAL ORM ONLY 1505610101 Side 1 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number ( Decedent's Name: J ~ 11 v~ ~ ~j ~ ' ~ ~p ~ J ) S ~. 'S RECAPITULATION 1. Real Estate (Schedule A) .......................................... , .. 1. ~ - - ~ 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 Pro e ) p rty (Schedule E .... ... 5. ~ ~ ~ '_ <, ~ t ~- % ~ 6. Jointly Owned Property (Schedule F) p Separate Billing Requested .... ... 6. .j cv ~`~ ~ ~ G 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property - (Schedule G) p Separate Billing Requested..... ... 7. t 8. Total Gross Assets (total lines 1 through 7) .......................... ... 8. ~ ~ ~ (~ ~ ~{ 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. ~ ~ 5 (] ~ L; ~ O 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. ~~ , ~. ~ - 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. _ ~ ~ ~ (\ - L~ 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. ~; ~ U (o ~~' • ~ f TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 _ ~ 16 17. Amount of Line 14 taxable at sibling rate X .12 ,, 17 18. Amount of Line 14 taxable _ ~ - at collateral rate X .15 18. 19. TAX DUE ....................................................... ..19. ~._ t _- ~~. !~. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: ~~.r~ ~ STREET ADDRESS l- - -- CITY Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 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. File Number STATE ~j1 ' ZIP I~~S~ (1) ~J Total Credits (A + B) (2) '` (3) (4) ~ (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 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. Ditl 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 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. O O O y ~ O u~ ~ lf1 y W N ~~ ~, .r., N p ~^ Q ^- ~ O 00 ?~ O pp ~ O y O O cV fs'" 7 ~ O~ N F" O ~a F A ~ '~ !A OD ~ O N ~ JJ Gl ~ N ~ a A ~ cir ur . c ~ G n ~ o •~ ~ ~ w A ~ a C1 G a U v .~ O y N •.-1 ~ V1 ~ A '~ 4+,~ ~ u~ a ~ °' ~ .a a - v ~ ~ ;o V1 ~ ~ b O ~ W a; ~ 0.i W ~ ~ 'd y ~ ~ N ~ •y rr' y ~ .~ o ~ ~ U ~ ~ `° ° °' A z ° w ~ F• i ° a s ~ ~ w w ~ o Q U ,° c ~ ~ q ~ ~+ v o U U b w y oo 'O ~ ' ~ ~ 3 o °' `" ~° b a i ~ a~ ~ ~ a i w b i7 ~ ~ O U h .r". ~ ~ i r" b C+ d ~ N ~ ~ ~ b N ~ u Q ~ 7 O ~ ~ 4 ~ .C ~ " N ~ ~ N ~+ ~3w b f F ~ 6 ~ U ~ ti ~` ~~ fl ` ~ O O M `+ O "` ~ i ~ c~ 1 J ~ '~ ~- , U ~ ~° o ~ ~F _N C ~ ~ O G, U d a~ A ~' w REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIED~ILE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ~%; h ITEM NUMBER A. 1. 'c ~ FILE NUMBER ~~~ 1 ~ ~ (^ Debts of decedent must be reported on Schedule I. FUNERAL EXPENSES: >j~ 1 ECG} C'~--e ~Q B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address -- _____ City State Zip _ _ _ Year(s) Commission Paid: 2 Attorney Fees 3~ 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• Accountant's Fees 6• Tax Return Preparer's Fees 7. >~1 ~l - /~ -vo ~. ~~(9 5D . cx% TOTAL (Also enter on line 9 Recapitulation) I $ ~ ~ J~fi C2'i (If more space is needed, insert additional sheets of the same size) ORIGINAL 110 -~_ ACCT. NO. LAST BALANCE $ ~/~~ _ -,,M,a~ t.~ Funeral Services `~~' / ..L/J~HECK N ~~~~_ CREDIT CARD __ ^ OTHER Name of Deceased FOGELSANGER-BRICKER FUNERAL HOME, INC. .Crt..~> ^ INTEREST ^ LATE PAYMENT CHARGE SUB TOTAL CREDITS LESS PAYMENT -~J~~~~ ~~ NEW BALANCE $ ~'~"'--- Q~3004 M~TBatili King Street 1-800-724-2440 Stmt p Indicator .'Da#~t~. Account History ***"3351 Classic Checking/Club 50 Checking tio~ Wlth~drawals !)eposlts Balance * 12/09/2011 CHECK NUMBER 2273 $41.70 * 12/09/2011 CHECK NUMBER 2271 $339.38 * 12/07/2011 CHECK NUMBER 2272 $376.06 * 12/02/2011 DEPOSIT * 11/21/2011 CHECK NUMBER 2270 $100.00 * 11/10/2011 CHECK NUMBER 2267 $41.70 * 11/09/2011 CHECK NUMBER 2269 $71.01 * 11/07/2011 CHECK NUMBER 2268 $60.00 * 11/07/2011 CHECK NUMBER 2266 $348.22 * 11/03/2011 DEPOSIT * 10/21/2011 CHECK NUMBER 2265 $160.00 ~_ This is not an official statement 01/11/2012 10:34 AM $507.00 $507.00 $3,856.84 $3,898.54 $4,237.92 $4,613.98 $4,106.98 $4,206.98 $4,248.68 $4,319.69 $4,379.69 $4,727.91 $4,220.91 1 COMMONWEALTH OF PENNSYLYANIA INHERITANCE TAX RETURN ESTATE t)F SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ~ E ~a FILE NUMBER IK ~`~.bi~ yC~o3 ~ ~'~ r, le. ~ Include the proceeds of a? / /1 d©3 h6gaUon and the date the proceeds were re~~ ~, the ' ~ pf°pe~ ~~Y-o~ with the right of survnrorship must be discbsed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE f, ~~ lL~ ,~ 5 ~~~~-C- OF DEATH ~ 3 ~.~ to - ~iy' TOTAL (Also enter on line 5 Recapitulation) I $ (If more space Is needed, Insert addltlonal sheets of the same size) f~V-7509IX+(1-971 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY ff an asset was made joint within one year of the decedents date of death, R must be reported on Schedule G. SURVNING JOINT TENANT{S) NAME B. C. JOINTLY-0WNED PROPERTY: -_..s~ FILE NUMBER ADDRESS ~ zZ S .~ f,er,S .s-~-y M ob,1c ~ s-r S~.~p~ s ~.,-5 ~ ~~1 t l LS l ~~ File tE 3 -7 ~ / -/..Z - GG RELATIONSHIP TO DECEDENT ~~ ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION DF PROPERTY Include vane ~ rx~alcial in5UW6pn and bank apt number «~ identifying number Attach deed fpr ~„til,~ ~ ~~ DATE OF DEATH VALUE OF % OF DECD'S DATE OF DEATH VALUE OF r ASSET INTEREST DECEDENT'S INTERE ~. A. f~ ~ o l f `1,v b, le 1-~m e - R 7 3 C boy D~-s 1 i o 1 ~ ~ ~ ~ n~ i I ~ rt~~,e ~'~.5 ((oS ~1 y(o So S' .q,~ ' . ~ ~t 5 p00 ~% . ~eZ 5vD Copy off -~ ~ le R-{-~~ ~,e.p $ -~'S o,r~ rer~~ Lo-c iT TOTAL (Also enter on line 6, Recapitulation) I ; ~ ~5 UD "° (ff more space Is needed, Insert addltlonal sheets of the same size) - ~~~ _ -. _ . . ~1FIG .lOtnnt tJi1:'g'~i _ =' .. - , -....-, y^ ~q _„ !y ~ ~,'. _.. __ -.. _ _~ _... _... ~~~T r~~~~~~~u ~,Q ~ ~C~ S D FROTHY R. ABY ii-9G PH. ii7z32-~2 122 SHIPFE\SBL'RG Ail?BILE ESTATES SHIPPF`'ODT'D`' DA ,~~c, 1Da'9 ~ ~ht acr o! t L.~ o."dtli6~a ~~ IQnp 99~eit OlRu ~tAB 6~a.y, pP x:03 L30 2955: 7996773614' i35 ~31~ss~ 113 5 - date "`" _ _