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Home My WebLink About05-14-12 (2) 15056041046 REV-1500 EX (05-oa) OFFICIAL USE ONLY PA Department of Revenue --~ Bureau of Individual Taxes County Code Year File Number Dept. 280601 INHERITANCE TAX RETURN ~ _ Harrisburg, PA 17128-0601 -~ RESIDENT DECEDENT ,~~ ~ I ~, ~._> ~j ENTER DECEDENT INFORMATION BELOW ~ `..."_.____ Social Security Number Date of Death Date of Birth goy y~ ~~~~ 0~~6~~> v e~~d~gd~f Decedent's Last Name Suffix Decedent's First Name MI G f t-' 3 c ~T ~' v tl N E (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 O 1. Original Return (~ 2. Supplemental Return ~~ 3. Remainder Return (date of death prior to 12-13-82) Q 4. Limited Estate Q 4a. Future Interest Compromise (date of ~O 5. Federal Estate Tax Return Required death after 12-12-82) Q 6. Decedent Died Testate (~ 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 {= 10. Spousal Poverty Credit (date of death Z~ 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 rf ~ ~! ~! ~ -r ~ :S' ~ ~ L g ~ ~ ~~ ~- i S ~~ ~ :~ ~~ S v Firm Name (If Applicable) ____ _ .- ~ ;.'~, : ~^t REGfSTER t~ jLS USE LZ~tLY , r- ~ ~ ~_ First line of address -r' .t ~ --< _ rJ Z o S c~~ S 'r ~l v 'r G t r` .J" ~` c_? ° r ,: Second line of address - -, ~.: ~. ` j ,~__ --° _:. -_! G-.) '{ _~ f D .C°" ,~~ City or Post Office State ZIP Code --_______."!~1~ F ILED_ ~~' --c~ ~ C 'P /~ g S i E i~ ,g ~ ~ cj ~ ~ Correspondent's a-mail address: _ i~ ~~362T.~i~n! `-lg~/ZC,~; i~~ f Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete~DeGaration of preparer other than the personal representative is based on all information of which preoarer has anv knnwlerlnp .~w~~h~vr[~ yr rr=rcwrv hctJYVN51 L FOR FILING RETURN -------~'"~°-- ®-'°'°~"°-""' _°"°~° - _ ADDRESS ".~ __.._ _....~~.~. r_., "..~.,"_ ~.,.. ,.., .. SIGNATURE OF PREPARER OTFtER THAN REPRESENTATIVE ~ ~°"""'"` '"" "'~-°-"-°`---°-~-° DATE ADDRESS - -~....._. -_.~__.__.,...-.-.....,._ ~,~- ~..__.-_"-~ PLEASE USE ORIGINAL FORM ONLY ~ -~~'"'~ Side 1 15056041046 15056041046 J ,~~ `s 15056042047 REV-1500 EX Decedent's Social Security Number ' '~i(/ C~ ~~ G ~ 7~ Decedent s Name: ~_ a~~___. . ~_~_~. ~ ~..__,._ .. 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 8 Notes Receivable (Schedule D) .......................... ... 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ ~ ~ ~ . ~ '1 6. Jointly Owned Property (Schedule F) d Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested..... ... 7. 8. --- Total Gross Assets (total Lines 1-7) ................................. -.~._._.a~_____-~____ __ _.~_ __.______ , ... 8. ~ a 47 9. _ _ Funeral Expenses 8 Administrative Costs (Schedule H) .................. _.__..r.~~.~. ... 9. ,...~ ~ Z ~ ~ ~ ~ S 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............. ... 10. ~ ~~. ~~ 11. Total Deductions (total Lines 9 8 10) ................................ ... 11. ~ , ~ ~ ~ / 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 'iD b ~ 6 ~ r d 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. ~ ,~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~1~ ~,..~ .- _ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ . 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ ~ 1 g ~ 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. . l 0 . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C~ Side 2 15056042047 15056042047 aEV-,sneEx.l,an COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ~Q~ ~ G,G~d2~i IGfC6 -«3.~ Indude the proceeds of Migation and the date the proceeds were received by the estate. All property jointly-owned witlr the right of survivorship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~s ; ~ ~ ~/~ ,Z~f7' ~L~S :rUU~,,,~ d5 ~ ~7- ,~,SU. fJC~ TOTAL (Also enter on line 5, Recapitulation) I $ ~~~' (If more space Is needed, Insert addlUonal sheets of the same size) REV-7511 EX+ (10-x) SCI~IEDVLE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: _ _ ~ G ~~' t. s'~LLI 1/'~ '/'U/~C2~t; t-IC~Mc 7 ~~r ~~c~.t c€wd ~T~~ey ~ 6 ys~ oc,- B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions ,,/ Name of Personal Representative(s) iC ~nl~~~ ~~j, (,~(~ r" Street Address ~ S C- if~SS T/V i/ T ~~ ~ - ~~! u~ ~~ `` D s~G~ - - City ~~•c.Nr> / ~ State ! ~ ZiP _ ~c~ !~7__--- 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 Retum Preparer's Fees 7. V ~ ~~ V J`,i0~ GLG~!/•~lG SJ~i'~Cr~s' ~S',CI/ ~Z~G G -~' irJ/ L Cs •~~ / C, / TOTAL (Also Qnter on fine 9, Recapitulation) ~ 7" ~ / ~ f J (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (gyp-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ ,~, FILE NUMBER .--~!? ~ ~ G= ~ ~~T ~rG -GQ333 Report debts incurred 6y the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ~~~ ~~~~~~ ~Na~ ~~ ~~ceucu, mseri aaamonai sneers of Ute same size)