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Home My WebLink About03-12-12 1505610101 REV-1500 °` t°, _t°' PA Department of Revenue OFFICIAL USE ONLY Pv~ Bureau of Individual Taxes ~~ a Courtly Code Year File Numtter INHERITANCE TAX RETURN PO BOX z8o6oi `~ ~ I I ~ LI ~~ Harrisburg, PA 17i28-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI Iff Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Sottial Security Number ...:. _ _ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW r~ 1. Original Retum p 2. Supplemental Return p 3. Remainder Retum (date of death prior to 12-13-82) p ~. Limited Estate p 4a. Future Interest Compromise (date of p 5. Federal Estate Tax Retum Required death after 12-12-82) d &. Decedent Died Testate p 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wilt) (Attach Copy of Trust) p 9. Litigation Proceeds Received p 10. Spousal Poverty Credit (date of death p 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - Tk18 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number //gyp , /~ , ~/7 .FS.x REGISTER` ~ USE~tLY m N ~ ` ` ~,.~ First line of address c i ~ - 1 - t/ '~ z.` t=_ Cs Ca ~.% ir" „/~ `.~ i ~ ty to ~`" ~.w ,, .C7 ~, ~~ ??~ - ~; Second line of address ~ = -~ ~ ~. ~ ~. ' TS ,~- ~ CO i QR City or Post t~ffice State ZIP Code 1 DATE FfLEO ADDRESS ~ J - r ` --~-~"" ~y~'°.~..~,,,.~pp_.._ ry ~.o_:.r~.,,,.~..~-....,.,.,. SIGNATURE OF PREPARER OTHER TITAN REPRESENTATIVE DATE ADORE55 PLEASE USE ORIGINAL FORM ONLY ~.~~~a~_.~'~-~ ..___....__ __.___________ Side 1 L 1505610101 1505610101 Correspondent's e-mail address: (~ ; ~ ,,, ,~ >'~r`+-.Ct~ ~ ~ tLra- Undsr perfettiea of per)ury, i dedare that 1 have examined this return, inducting accompanying schedules and statements, and to the hest of my knowledge and belief, it is true, correct entl complete. Declaration of preparer other than the Dersonal re°resentative is hasarl ~~ ou ;.,r mnr~.,., ,,...n,...w ...e..e.,.. ,,,.,, ,,.,.. ,._~.._~__ J 1505610105 REV-1500 EX r b e dent's Social Security Num Dece ' ~ ~ ` d ~ ~ `~` ~ ~ 'y+ ` s Name: Decedent 1 J RECAPITULATION 1. Real Estate (Schedule A) ........................................ ..... L ` C7 2. Stocks and Bonds(Scheduie B) .................................. ..... 2, ;;_:• 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~; • 4. Mortgages and Notes Receivable (Schedule D) ...................... ..... 4. L:, • 5. Cash. Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. ~' '~"'• 6. Jointly Owned Property (Schedule F) p Separate Billing Requested .. ..... 6. ,~ • .. . 7. inter-Vivos Transfers 8 Miscellaneous Non-Prebate Property (Schedule G) ~ p Separate Billing Requested... ..... 7. : ~ r: ., - 8. Total Gross Assets (total Lines 1 through 7) ............ . .. ... ..... 8. yW _~ ~ ;r ~ . yr ~ 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. ~ ~"° ~ '„~ • •; .• - _ a 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... ..... 10. x`` 11. ............. Total Deductions (total Lines 9 and 10) ... ....... .....11. `~ 5 Y ~i~ ~~ €'. 12. Net Value of Estate (Line 8 minus Line 11) ................. ..... . ..... 12. ' ~, . 13. Charitable and Governmental BequestslSec 9113 Trusts for which ' an election to tax has not been made (Schedule J} .... .. .... .... 13.. C5 • 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. ...... 'i4. ~` • TAX CALCULATION -SEE tN$TRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line i4 taxable "` ' ~ at lineal rate X .0 _ [ 16. ° • i 7. r. .__ Amount Cf Line 14 taxable __ at soling rate X .12 ~`, . 17. ~ ' 18. Amount of Line 14 taxable ~`' 18 ~'`` • at collateral rate X .15 . 19. TAX DUE ................................................... ......19. td~~ 20. fILL iN THE OVAL !F YOU ARE REQUESTING A REFUND OF AN OVE RPAYMENT t~ Side 2 ~„• zsos6ZO1OS 1s~s~l~~as ,~ ~I~~.c}Z ,~v.~mn~x,t~An , SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, 8c ~~SC. INHHEERSIDENTDECEDENT~ PERSONAL PROPERTY ESTATE OF FILE NUMBER ~, ; ~ / - ~...~ 1. t,` Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survNorship must he disclosed an tdchadulo F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF pEATH ~~- ~.: a ~~,; , t ~ t • fir r r ~, ..~ ~ ~~,`s ~ TOTAL {Also enter on line 5: R~.epitulation} ~ $ ~ ~~ ~ ~ , ,red (It more space +s needed, insert adddional sheets of the same size) REV-1bn0 FX Page 3 File Number Decedent's Complete Address: ~ ~ °-= ~ ~~ ` ~-` ~= `~ ~' ~~ r .i ,_ , STREET ADDRESS tr,._ ,;...,, .._.. _ ______ - .. _ CITY STATE _ 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. Filt in oval on Page 2, Lute 20 to request a refund. (¢) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. [5) ~ ~" ~_ Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" tN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No • -, a. retain the use or income of the property transfered :......................................................................................... [J t b. retain the right to designate who shail use the property transferred ar its income; ......__..........__.._....__....._ ^ i c. retain a reversionary interest; or ................................................................................................._._............ _ ~ d. receive the promise for iife of either payments, benefits cr care? ..........._ ................ ^ ~`` 2. ':f death occurred after Dec. 12, 1982, did decedent transfer properfi? within one year of death . r~ without receiving adequate consideration? .................................._...._..............._..............._.........._......._ ._..... _ L_ I !. 3. Did decedent awn an "in trust for" or payabie-upon-death bank account or security at his ar her death? .............. i_J' i~~ 4. Did decedent own an individual retirement account, annuity ar other non-probate praoerty; which contains a beneficiary designation? ....................................................................................................................... ^ +.~' IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COiYIPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Far dates of death on or after Jury 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to ar for the use of the survmng spouse s 3 percent (72 P.S. §9116 {a) {1.1) (i)). For dates of death an 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)j. 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)]. s The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benef+ciaries 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)j. Asibling is de~ined, under Sectir~n 9102, as an individual who has i?t Seast one parent in mammon with the decedent; whether by blood or adoption. (1) _ ~ Total Credits (A + B) (2) REV-1511 EX+ (10-061 ' ~ ~ ~ SCNEDVLE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT i ESTATE OF FILE NUMBER / ~` C3a- ,.l ~t~ f ~'~t 1 ~" J ~~ d a .~. t:si 'fir (j ~- Debts Ot decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~~,~~ B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) _____ Street Address City ---___ .._ _ _.__ Year(s) Commission Paid: State __ Zip ~ ' 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 A. Probate Fees ~ l =°~~ 5• Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) I S ~ ~: a; ~ ,~ ~l (If more space is needed, insert additional sheets of the same size)