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Home My WebLink About03-30-12t t • ~ 1505610101 REV-1500 IXl°=-=°' ~' PA Department of Revenue PeMfSylvania OFFICIAL USE ONLY ~~^TM°M°^^~^ Can Code Year File Number Bureau of Individual Taxes b PO Box 28D6oi INHERITANCE TAJC RETURN ® ~ / Harrisburg, PA 1732&0601 RESIDENT DECEDENT I ~ ENTER DECEDENT INFORMATION BELOW SociTal Security Number ~ Date of Death MMDDYYYY Date of Birth MMDDYYYY G1lrp,~B ~~~ l-crl 'S1 ~ C1~~iL~1~~ 6 0 ~ 8 19 5 ~r Decedent's Last Name Suffix Decedent's First Name MI Q (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's~First NameTrr MI i ie ll__1111J~N_N_L 1 CJ IIIIIIIII?~ Spouse's Social Security Number ®~~~~ ` ~~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t' 1. Origmal Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-132) O 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) ~ 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 Number First line of address Second line of address City or Post Office State ,. r. ... , REGISTE LLS USEeONLY ~ ~ ;, C> T C7 7q ~ -~ C . :3!_7 ~ c -. ~c ~* ._ T ~ C- rv ~ ~ - m ~ N ZIP Code l E FILED ~~ 4 - Correspondent's a-mail address: Cnc~r 1"1"YI ~ ~ L,Q~~~ [ ~ Under penalties of perjury, I declare that I have ex ed this return, including acco panying schedules and statements, and to the best of my knowledge and belief it is true, correct and complete. Dadaretlon of preparer other than the personal representative is based on all information of which preparer has any knowledge. IlpNATURE OF PfcRSONIi~SPONSI OR FI R6TURN DAT ~) 3-I~-~oiZ. ADDRESS 1 ~Ro1~a n ~rt ~ e~J~ ~ ~ ~ A 1-L2 ~4 ~ SIGNATURE OF PR~ARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 7 1505610101 1505610101 J l r J REV-t500 EX Decedent's Name: s~nwmm~ wrnwr 1. Real Estate (Schedule A) ............................................. L ^ y~ ~~~.~. ^~^ m .^~ m D Q 2. stocks and Bonds (Schedule 8) ....................................... 2. D b 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. A V 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ~ d 5. Cash, Bank Deposits and Miscellaneous Personal Properly (Schedule E)....... 5. ~ ~ ~ r ~ / (p 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. D ~ D 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Biling Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ Q 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. D V Q 11. Total Deductions (total Lines 9 and 10) ................................. 11. ~ f7 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. 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 °° ~'"''9'A°("~~ (a)(1.2) X .0~ A ~ 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of Line 14 taxable at sibling rate X .12 78. 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 1505610105 Decedent's Social Security Number O Side 2 1505610105 1505610105 J REV-1500 EX (FI) Page 3 FII• Number Decedent's Complete Address: DECEDENTS NAME , 'n'~ ~ (~ t t:,~ STREETADDRE ~e T S rPS CITY ~ I ~ STATE ~~ ZI~ ~ ~ ~/ /~P~ v1 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments ~p~r A. Prior Payments ~ _ B. Discount ___-~ 3. Interest (1) Total Credits (A + B) (2) '~ (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, Llne 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) '{'~~ 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 properly transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ '~ 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 Uvst for" orpayable-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 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 benefidary. Far 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(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-1WB IX • (7971 SCHEDULE E CAMMDNwEALTHOFPENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHERSIDENTDE EDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER S R~~ Indu a the prooeeds of li6gatfon and the date the proceeds were received hY the estate. All properly joimlyowned wHh the ripM of survivomhip must bs discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. ~Ce~.al L~~i9~~-~~n RPC~vD~1 !~',RI•~611 /3~ l1'7.lob TOTAL (Also enter on line 5, Recapitulation) I i / 3 ~ ~ /7 , ~ 1} (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-x} I!N#RITANCE TAX RETUIW RB1DBfT DECED9f~ SCHEDULE BENEFICIARIES ESTATE OF ~ - FILE NUMBER S~phe~ m. R~~~.. REUTIONSHIP TO DECEDENT AMOUNT OR SNARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Ttu~Ibs(s) OF ESTATE I TAXABLE DISTRIBUTIONS (Include ouMght spousal dEstrilwiions and transfers under sec. 2116 (a) c1.2)a ~ ~ - i 3, -1 i . ~, O 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRUTT:. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DIS'iRI8UTI0N5 UNDER SECTION 1113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN ~„ 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON TAXABLE DISTRIBIRONS ON LINE 13 OF REV-1500 COVER SHEET. ~ ~ ~ ~ ~ ~ ~ p