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HomeMy WebLinkAbout03-27-12 (2)___ J 1505610101 REV-1500 °` ~°1.1°' ~ PA Department of Revenue pennsylvartia OFFICIAL USE ONLY Bureau of Individual Taxes OFMRTNERTOFREYFNUE County Code Year File Number Po eoxs8o6oi INHERITANCE TAX RETURN Harrisburr~, PA i7~28-o6oi RESIDENT DECEDENT FILL IN APPROPRWTE OVALS BELOW Date of Birth MMDDYYYY Decedent's First Name MI Spouse's Last Name Suffix Spouse's First Name MI ®r~~-r-rr~ ~ o Spouse's Social Security Number r THIS RETURN MUST BE FILED IN DUPLICATE WITH THE "TQ'T~'T~TI REGISTER OF WILLS ENTER-DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY t 1 ~+ ~~ ~L~~~ Decedent's Last Name Suffix (HAppNcable) Enter Surviving Spouse's Information Below ~ 1. Original Return O 4. Limited Estate ,~ 6. Decedent Died Testate (Attach Copy of wilq O 9. Litigation Proceeds Received p 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 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 12-13-8,2) 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 r a G ~j ~- RE6ISTE ~ LLS-U3Er~1LY ~~ First line of address ~ ~ ~" ~. ~' r*~ ~D Pi ~' ~~x -.rl -~ {- ' C~ Second line of address ~~ ~ 3 ~---~ ~ ` r--t City or Post Office State ZIP Code !!77~~~ DATE FILED ~ ~j 1 ® ~~ nu~w~ Correspondent's e-mail address: ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ C ~ r , ' Under penakies of perjury, F declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge aild belief, it is true, coneCt and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any know) SIG E OF PERSON. RESPONSIBLE OR FILING RETURN DATE , ADDR~SSZ ~ ~ "'~Y~'~ / f ~„~[ ~ ~ ~Vli~ \`i S K./ ~~ ~ ~ ~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 1505610101 J t ~ J 1505610105 REV 1500 EX i ' Decedent's Socal Security Number Decedent's Name: ~ ~ G V • `~ ~' r~ ~"' ' RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. .n ian goo nn V . 2. .Stocks and Bonds(Sk~edule 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 Properly (Schedule E)....... 5. s 6. Jointly Owned Properly{Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vrvos Transfers 8 Miscellaneous Non-Probate Property {Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................ 8. 1 m 9. Funeral Expenses and Administrative Costs (Schedule H).........:......... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........:..... 10. 1L Total Deductions (total Lines 9 and 10) .............................:... 11. 12. Net Value of Estate (Line $ minus Line 11) ...............:.............. 12. >: 13. Char¢abte and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. _ .' _ ,. 74. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX;CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable - atthe spousal tax rate, or transfers under..9116 16. Amount of Line`14 ta~ple at lineal rate X .0 ~? 17. Amount of Line 14 taxable at sibfing rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE ......................................................... 19. 20: FILL IN THE OVAL IF YOU ARE REQUESTING. A REFUND OF AN OVERPAYMENT siae 2 -~ 150561010.5 150561Ob05 ~ - -~j O ' REV-1502 EX+ (11-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE 1 ~~ 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. If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) SCMEpVLE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned wfth righkof survivorship must be disclosed on Schedule F. (If rrrore space is needed, insert additional sheets of the same size) REV-7504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF ~ t FILE NUMBER 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 cola-nrnnrietnrshio. See instructions for the suooortinq information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDI~LE C-1 CLOSELY HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Product/Service Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STACK VotfnglNon-Vating SHARES OUTSTANDING pAR VALUE 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. 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 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 Attach a separate sheet for additional transfers and/or sales. Consideration Date 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 decedents 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 addresses 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. Date of Incorporation State Zip Code Total Number of Shareholders (If more space is needed, insert additional sheets of the same size) KIEV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpVLE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF ~"~ ~~ ~ FIL~ENU'JMB ~ \ _ ~ ~~ ~Z i3-e~c~ S,. ~~ ~ 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-1506 EX+(9-o0) SCNEDVLE C-S COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address Business Reporting Year City State Trp Code 2. Federal Employer I.D. Number 3. Type of Business ProducUSeroice 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. 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 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 receved. 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 values. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. 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 REV-1507 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SC1~1EDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF ~~ FILE NUMBER All property jointlyowned with right of survivo ship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-150~IX • (1b~ SCHEDULE E COMMONWE4LTHOFPENNSYWANIA CASH, BANK DEPOSITS, ~ MISC. iN RE~iDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF ~ FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-owned with the right of survhron3hip must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ce CCc~~ ~~~~ ~n~ ~ ~ 5 ~~ ~~J-~~ ~ ~~ -A- ~~~ ~1 ~--T- ~ a h ~ ~~. l t~r~-e- ~' S t1--1,•~ s ~~ ~~ ~ ~ ~ ~' ~ ~ ~?oo~ ~~-- `1 ~ o~ O x-~.-o ~ ~ y~7~ ~ P ~ ~ ~ < < ~ _ ~~ l~ TOTAL (Also enter on line 5, Recapitulation) 15 ~ ~~,~ q ~z-~. ~~ (If more space is needed, insert additional sheets of the same size) aEV-,soe oc. l,an SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF ~ ~~ ~` ~ - 4 FILE UM'BQER ff 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 A. JOINTLY-OWNED PROPERTY: RELATIONSHIP TO DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial insfilufion and bank account number or similar identifying number. Attach deed fajointly-held real estate. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTALi(Also enter on line 6, Recapitulation) I i (If more space is needed, insert additional sheets of the same size) REV-,5,0 EX • h.en CAMMONWEALTH OF PENNSYLVANIA INHERITANCE 7AX RETURN SCHEDULE G INTER-VIVOS TRANSFERS 8r MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ff~~ - v - Thisschedule must be completed and filed if the answer to any of questans 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY IHCWDETHEHAMEOFTHETRANSFEREE,TFIEIRREU7IONSHIPTODECEDENTAN~THEDATEOFTRANSFER nrucHncowoFrHEOEEnFORr~uESrnrE. DATE OF DEATH VALUE OF ASSET °~6 OF DECD'S INTEREST EXCLUSION iFnPPUCnai.E TAXABLE VALUE 1. ~ 0 h-Ci TOTAL (Also enter on line 7, Recapitulation)' S (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCNEDVLE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8t INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM A. I FUNERAL EXPENSES: 1. ~v.c.. 7 cl ~~ ~~o~ ~'~!-C.. f ~~~41'' (-~1- lct -I1 . L~ wind ~~ ~.,~ Cte v~nt~-~rG v'Y ~,enr~-~.~ ~ ~ ~ g s. ~ ~ Soo Yw v~ j of .~ ... ~ ~ It,c,.. s-~.~..~.~ r2~ ~k..~e..d~ 5.~. ~ ~4 ~ g ° ~-t Ca , B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions ~~~~ Name of Personal Representative(s) _L- - ` - - - ' 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. Accountant's Fees 6. ~ Tax Return Preparer's Fees 7 TOTAL (Also enter on line 9, Recapitulation) I $ ~ ~j{p~, 4, (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 ESTATE OF `` `` FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpt~LE J BENEFICIARIES 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 ec. 9116 (a) (1.2)] S 1. + , ~} ~ S ~~~ ~ r ~~ ~ ~,` ~ ~~~~ v 1 Z Z Z ~ e ~~t ~ b~] ~ v~-r ~,~~~-~1~e P~} ~~ o ~-~ ~ ~~ 2~ ~PP~~d~~- ~~7 Z C S~r~~ ~. C -~ °I 13~`t ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET lI 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 $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEDIJLE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover SheE ESTATE OF FILE NUMBER i3,e ~-~ ~ . 1~v..r~ t_.. ~.a ~ ~- ten"'? a Z. 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 NAIAE(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT DATE OF DEATH t7K ~S 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(3) OF LIFE ANNUITANT(S) DATE OF BIRTH . ~ NEAREST A{3E AT DATE OF DEJrTH ANNUITY I5 P/IYA~LE ^ 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 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 Llne 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Llne 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) P.EV-1615 EX+ (1-85) INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREP/aYMENT ELECTION ~ `~ ~ ~ ~ ~ ~ Q INHERITANCE 7AX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER ~ 3 I. ~ ,~. , dte o~ (Lost Name (first Name) (Middle Inition II. Itelm No, Descri tion Value A. Real Estate (pleose describe) Total value of real estate $ {include on Section II, Line C-1 on Schedule L 8. Stocks and Bonds (please list) Total value of stocks and bonds $ indude on Section I1, line C-2 on Schedule L C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (Please list) Totol vahie of Closely Held/Partnership $ indude on Section 11, Une C-3 on Schedule L) D. Mortgages and Notes {please Gst) Total value of Mortgages and Notes $ indude on Section II, Line C-4 on Sd-edule L E. Cash and Miscell~ous Personal Property (Please list) . J O ~ '~ ~ 7 Cf ~~~ ~~ Total value of Cash/Misc. ars. Proppeerty d /.- ~`° ~ V in ude on Section II, line C-5 on Sd+edule L 1~ ... . IiP- 111. TOTAL (Also enter on Section I I, Une C-6 on Schedule L __ _ $ / _ ~ ,,~ f ~ • . (If more apace is needed, attach additional 8!~ x 11 sheets.) REV•1b46 EX+ (3.84) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA IN RN E REMAINDER PREPAYMENT ELECTION ~ ~ ~ ` ~ ~ DECEDENT RESTDENT -CREDITS- FILE NUMBER ` ` ~ ~ S ' ~ I. -~- ' Estate of u- -~ (Last No ) (First Name) (Middle Initial) I1. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) 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 II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line. D-4 on Schedule L) $ ~Z (If more space is needed, attach additional 8t/z x 11 sheets.) • REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEpt1LE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF ~ ~ ~ ~ , ^,~ `~~~ ~ FILE NU~MBE~ ~ ` _ ~ Z ~'~ O ~ ~ This Schedule is appropriate onty 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 L Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if 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 III. Explanation of Compromise Offer: N Summary of Compromise Offer: 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) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) INHERITANCE TAX DIVISION EST~4TE OF FILE NUMBER This 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) ............................................ 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) ........................................... 9. 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: 11. a. Spouse ........... ia. b. Decedent .......... 1 b. c. Joint ............. 1c. d. Tax Exempt Income .. 1d. e Other Income not listed above ........ ie. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) _ + (3f) 3b. 3C. 3d. 3e. (+ 3) 4b. Average Joint Exemption Income ..................................................... _ If lino d/hl is mm~tnr than ~dn nM _ CTAP Tho natato is nni alinihla fn maim tha crarlit If not rnntinua to 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less 2. Multiply by credit percentage (see instructions) 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 . .............................. . 4. -For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................ . 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...... . Part • 1. 111. ; 2. 3. 4. 5. REV-tS~S Ex. (1-s~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE 0 ELECTION UNDER SEC. 9113(A) FILE NUMBER 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 applies to the Trust (marital, residual A, B, By-pass, 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 arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's (If more space is needed, insert additional sheets of the same size) `__ REV 1500 EX Page 3 Decedent's Complete Address: Ftle Number DECEDENTS NAME ~ ~~ ~ 1 {~ t /I~ STREET ADDRESS CITY (, _ ,I ~ \ '~J~ STA~ ~ ZIP ~ O r Tax Payments and Credits: L .Tax Due (Page 2, Line 19) 2. CleditslPayments 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, Une 20 to request a refund. (4) t1) L/ ~ Z, ~~- 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ "l Z . Z ~ 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. retrain 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 rd without receiving adequate consideration? .............................................................................................................. ^ ,t~~/ 3. Did decedent own an "in trust for' or payable-upon-death bank account or security at his or her death? .............. ^ 19 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND ~It-E R 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 dist~osure of assets and filing a tax return are stiN applicable even if the surviving spouse is the only-beneficiary. For dates of deaftt 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 tt~e 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)172 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.