HomeMy WebLinkAbout05-21-12 (2) 1505610101
REV-1500 Ext03_1°' '
PA Department of Revenue Pennsylvania OFFICIAL USE ONL`(
-
Bureau of Individual Taxes oEa"w,~E"' .aE°`"°`
~ County Code Year File Number
INHERITANCE TAX RETURN
PO BOX z8o6o1 `
Harrisburg, PA 1']128-ot5oi RESIDENT DECEDENT
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ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
-~C?~ ~~ l 6~C? 03i I X 01 ~ G~~:`; I~ ~y
Decedent's Last Name Suffix Decedent's First Name MI
~~Au~ ~LCE-I ~I2,l~ C
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return
O 4. Limited Estate
~ 6. Decedent Died Testate
(Attach Copy of Will)
O 9. Litigation Proceeds Received
~UfZRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO
Name Daytime Telephone Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
O 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 12-13-82)
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)
First line of address
~~y~ ~,u i vtiw~o9 ~ ~ ~e ~~:
Second line of address
City or Post Office Q
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State
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ILLS U3E~DNLX -- ~
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GP,rE FILED
ZIP Code ~
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Correspondent's a-mail address: ~ CYl S ~S ~'~ G 7 e ~( ~' t~ t Z 0 t7 , O E t
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, anti 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.
SIG R~ OF PERSf~N RES,,~~ONSIB E FORr FILING RETURN M ~~ ~ D TE
~ (.._.._..~'r~'' ' GEC .~. ~..1 ,~ /.(., _~
aay0 ~uff~~~ ~ ~ C`~r~~=J~' ~urrf5burc f ~I ~ , ~ ~_lfU _ _
SIGNATURE OF PREPARER OTHER THAN REPRE ENTATIVE ~~-~~-~-i ~~~ ~'~~""~ ~ "-°"
~. DATE
. r._._____.,.-_ _- _..~~_,p..__~.._._.~r.._-_.._._......_._........_..,.~.__~
ADDRESS
~~~ _ r-~~_ PLEASE USE ORIGINAL FORM ONLY -~.._..~._-~ `°
Side 1
1505610101 1505610101
J
1505610105
REV-1500 EX er
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ent's Social Security N
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Dece
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Decedent
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 Property (Schedule E)..... .. 5. r
i
.~ a`
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. •
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) p Separate Billing Requested...... .. 7. •
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""'111
8.
( g ) ................
Total Gross Assets total Lines 1 throw h 7 ......... • ~ ~ ~ 8. r , y
.
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9.
Funeral Expenses and Administrative Costs (Schedule H) .................
.. 9.
~ ..
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10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. •
11.
Total Deductions (total Lines 9 and 10) ...............................
.. 11. ,i
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12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ ~-( '~:
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;'~~ 0
- s
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. ~I r_
„~ ~ ~ ~
~ ~1 f I ~,
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
(a)(1.2) X .0 _ .
16. Amount of Line 14.~~axable
~~
at lineal rate X
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0 ~~ 16 ~ l ` ~ ~ '`',
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.
,
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1
17. Amount of Line 14 taxable
17
•
at sibling rate X .12 • .
18. Amount of Line 14 taxable
'
18
•
at collateral rate X .15 .
..19. ~ ` ~ ~ ~
19 . TAX DUE ...................................................... .
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Side 2
1505610105 1505610105 J
f2EV-1500 EX Page 3
Decedent's Complete Address:
File Number
D EDENT'S NAME
~~4~ar_~(__C ,_ C_~ c~a u
--
__ _ _ ---
STREETADDRESS,_ -
- - ---
- _ -
-- ---- _
------- ----
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-- --
STATE ---ZIP -- - - -- .
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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
Total Credits (A + B) (2) 5 5 ~ ~ ~
(3)
(4)
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. 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 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.
REV-15o8 EX+11-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
OF
SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
PERSONAL PROPERTY
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATI-I
1. ~v0`i ~`7iAiCK ~cC~(itl ~ ~.~~
~z ~dizSPhal~ Fut"ni~cr l,clr~n~ I~pn Std, (~~a(~-m ~~ (G~ont~S~ S~u~S tfr `r ti
~ ~hct1 ~ittc211 f<.CG
~= Che~~~tn~ u~c~, ; SU~~«sc~ }?~
_~ :,~,:~ t~~~ a ~Ytt ~ ;'Ii I ~
C~hPr~Ctn~ CiCCou of ~+ 5'111 3~+aG'l ~ 3$~~ ~~ 1 ~ `6 ' ~. I~(
( ~ UP;"Lulu ~ x,3-3 5~3 `~~ ~3 ~ lei d7,~i~/oC) ~ ~~~
I~'1 G,~,~ ~( 11'10 C ~C2~ r,~ l C ~ ~" 10 5) (; ~l C6 ~ ~ ~ ° I I) bps?, h~ ~
TOTAL (Also enter on line 5, Recapitulation) ~~ i i ~ ~~ ~ ~ LS
(If more space Is needed, Insert addltlonal sheets of the same size)
REV-1,511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE N
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
EST OF FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM -
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' ue'c C rt n1~t ~
~C~~ll~C4 (~',t~e.il ~ -~-t\ffC~~`~ ~l ~COIG(tt~~ ~-2~y ~C(S
5~c-tom( ~[c~(,{s ° ~~cchnS~ ~ (~~~zn~znr~ Cc~C~ 3u~t~
~c~~>{ ~'lc~fc r flarri~ can ~~(~~C yat~S~C~~t~+ art ~~n~ ~4 CcY~~ 3~t~f
"~ c ty '~ i~c~~~~ r ~~ ~{ G-~ ut n ~'~ ~ SS qty ~r ~ c~~~ ~ F~ 1<;f 5`15
II~~.B't'~.dCu~ jd('u+,tc`, C1~Q1Ywt~ial ~11~t~c~5 ~ (~+~Y~~ctU~ hull4~in5~
. ~`(1~ntS-Et,~-~, U, 5. fl~,~~~~1 l~5<~~,'~:, ~'1~a,~ers~ I UC~~
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.
TOTAL (Also enter on line 9, Recapitulation) $ rt 1 r ,1
(If more space is needed, insert additional sheets of the same size) mil
REV~1513 EX+ (11-08)
~ pennsylvania SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF ~ FILE NUMBER
- ~Zh.~ ~ ~~ ~tu ~ ~C~~~ - CU.3y7 _
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY REDoTNotSList T ustee(S~NT AMOOF ESOTATE ARE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
/~ Sec. 2116 (a) (1.2).]
1. ~~~YIN(C! I,! S(Y~i~~ VCcuLj1't'~s~~ ~~U
a~~b 1'~ut_4~nu)o~~( C'l ~rc(~ti (~(~~~ t ~bu~
n
5 U ~o
~ Clc~:~ t Cc I (!~
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A, SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
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 neetled, insert additional sheets of the same size.