HomeMy WebLinkAbout06-01-12 1505610105
REV-1500 Ex 1°2.11, IF[, ~:
l
i OFFICIAL USE ONLY
van
a
PA Department of Revenue Pennsy
Bureau of Individual Taxes "r"~.~E~. `
~ INHE County Code Year
RITANCE TAX RETURN File Number
~ ~ i i
PO BOX 28°6°1
Harrisburg, PA 1'Ji28-D6oi RESIDENT DECEDENT ' _
~~~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Narne Suffix Decedent's First Name MI
~5~~~ N r~ ~~ ~ ~~ ~~ j-i ~~ ~ S ~1A~T~ I A ~ ,~
(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
® 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
® 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.)
O 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 Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX fNFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
First Line of Address
Second Line of Address
City or Post Office State
ZIP Code
T ,~»
_.. ,-
Correspondent's a-mail address: ~'/
REGISTER OF WILLS USE ONLY
n -.
1- C_
rt_ r-
DATE'FIL•Ed ~ 'X~a
- -- -,"°
~_ _ ~.
~-
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and 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.
OF PERSO$PO I`B~..E~FOR FILIN~ETURN DATE
DDRESS ~,
'' > J: --
~ /05~" ~ ~ti ri3~~~r~~ y t-, ~ cwL T~~ _ Je~ r r~-- I 7 3 i ',~
SIGNATURE OF PREPARER OTHER Y AN REPRESENTATIVE T' DATF_
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105
1505610105 J
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~~
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1505610205
REV-1500 EX (FI)
Decedent's Social Security Number
Decedent's Name: / I~~G°t'_ Y 1 ~ ~ 1 /~- -~ L--~:. 6~7 f',7 C~ l.d t~ G 1 / ~~ ~ .. j ~ r .. ~,~`~ .^-7-~
s /
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1.
.:, _, ~ .. fr ~, ~
2. Stocks and Bonds (Schedule B) ....................................... 2 ~ ~r s-1-/, ~ l
~ /
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. ~~'` ~h ~'~ ~ /`~ - J
.~
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ... .... 6.
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.... .... 7. /~// /<f~~' J , ~ ~~
8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. '~
t ~ ~~' ~ '~~-
9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. C/~ ( <' //
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ........... .... 10. / ~' t'7~, r„
~
11. Total Deductions (total Lines 9 and 10) ............................. .... 11. ~
U~ ly I
~' ~ ~~
_ ,
12. Net Value of Estate (Line 8 minus Line 11) ..... 12. ~~" ~`' j~ ~ ~~
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. ~~(~~, ~ 4"`~'~ ~ ,,~~'~~j
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
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 _ 1g,
17. Amount of Line 14 taxable C~
at sibling rate X .12 ~°~
J ~ ~~' ~ ~
17.
/
Cr
~/~, f~ ~%
18. ~
Amount of Line 14 taxable /
//
at collateral rate X .15 18.
19.
TAX DUE ......
19.
~ ~.
C> ~ r ~'
C3 ~/
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610205 1505610205 J
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
STREETADDRESS ~ J -~ -
"~ _ n
- -
CITY
_ STATE ;ZIP - ---
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)
(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 ...................................................................................................................... ....... ^
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 tS 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(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-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
~~! , i.- ttt r ~ ~ ~~ LZ l71 ~' Gi- ~.~- 4,~r.
All property jointly-owned with right of survivorship mu ~ be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ~(
-/ ` j, I S/ 6i. ~,s ~.~'~. //S h t-,~~ 1~[.~r'=~~y ~ ti fit- ~._+)rr ~7e c.. ~~J ~ ~ ~,
~ / , J . ~ ~ {) a ---'~S Gf. /La. 5 ~ r i ~ ~.- ~r t~~, ~2~ ` t,~ -~.~ << +~ ~ I'e ~''t_~ "~"~ r, ff ~ ~r 1~ ,J ~ .., / ~
~° ~
s /~ ,~1
~S'~
y / /` / Q
..5 1~,~', / ~{')<r.rt's _~YIL~~YI)lrnf C~c'1s ~~ /1y~C!-ll.~~- ~} ",~(L~~~.
>>~ .3 ;2 ~ ~ 3a
' ~' ,~ c~~c~~- C /u fs .~3
~, ~ , ~ Gc -a e.
~~ l ~~3 , f ~~ a-r" ~ t - .- -~ 3 ,z ~.~ , o _3 ~ n ~~
,1(.C7r1e 411~~~
/,~.. G'~
Sl,a r-,vs ~r~+C r Icc7- ~ a- ~Gt ~~~-c ~,..'~Y d C,(~ss I~'
~-~ ~- ~~ ~ ~, ~ ~ ~ 1
<~~~„~
Cis, j' c1:~~b~!lD.zc`~~"
2 ~ d ,-mss
~~~ ~» m ~" ~-e
AAI~ ~.~t ~1.lz^~5 ~ ~d l~
V ~ l~6c, r"- \ F
1~~
~; ~_k%~c-r' d ~En FS
)~s ~ d ~ -' `'" .
1~'~'
TOTAL (Also enter on line 2, Recapitulation) $ ~ ~j /-~.Z '~ C~ f
.-... -- ,
(If more space is needed, insert additional sheets of the same size)
REV-i5o8 EX+ (u-io)
Pennsylvania SCNEDVLE E
DEPARTMENT DF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. m
~; ^ ~/.
f•- ~ >
,.,
-y, ,
~~ar~~ ~ ;' ye^ l`3 d :'uL+ ~i!"ApPY` ~~ C~I'Y1 I l cL ~ ~ ~} ClI ~ t'I Or't' rb~ ~I;'-"~r'~~P +' J~
7 - 11 1 J
e~'
h /, ,-~~,_~ k (°c ~~ - d „~..~ ~z; L~ ,~ 11 .: ~tcJ,.t_.; ~,14.~.1-e ; '~S'~J c'f,a~,.- yl-~'>~rm. ~,=
yr c S'
r ` 4
l..f AIL 1 I'S .- ~% ~ 'J'"~'~",~C ~I~;' /I! ~- (J ,.~ L' ~ ~~~ ~ % J
V ~/ ~ ~ G, 4"
•.5 . ~ ~ t i~, k , , , , ,..~ ~.--„ c ..., t a~„ ~ ~`J-c ,>, r~-I ~ ~,~:~- L=~.T ~ /3) c~ 1, fa~.~:..z~,zq~„ ~ C~t~ e",. Q?
(, 1
I. ~~nE~-~..,cl r F C'~~I~~led G~..~.~-D rii~.~:z~.-..rte ~~~Y~MI~N~ ~/.l/~-Z Z~Gt. ~~
/C' f ~ F~ ., d i ~ ~~t . ~ie ~ c> : ~ ~ ~~~?~L~ , ~
x.~ !' G~...rrt~" C ~~ r err ?~ ~/ Z_
c~ _ J c~ li'
~~~• 1
~/~/~ ~ .._
t' i 11~ / /C~ns: c:, (~'~~Ik~ ~ ~ ,j',c.~-Titc.~ }=a i- /J, ,
/ ~ ,~C y?, I~~~
l ~~ ~ r~ .a~5 ~, 7. ~', ~_'
/ ~~, ~~ r' .r r ~ ~ S a- ~ e ~ l~ ~ c. YSo ~~ ~ ) 'r~ P L >1 ~~ ~ /~1 ~ ~t ~,c'-~ a' ~ ~" ~ ~i c r~ j/y~~~ / 1-~ ~-~i ~ ~; ~~
~S' .~-' ~
LLi~)-~rr~~ Gn t!~~~IC,v,~ /~GC'~. ~~~ii--
~~~3s1
i
i '7 ~t /~ o-,+'- - ~ ,~«, n, r~ r'arrSo nk~~ l rt'I-IS -/~~. ~~-d~A~~."f~` ~` >/az~~ ~- :~/~, G~~
TOTAL (Also enter on Line 5, Recapitulation) $ ,/,~~ .~~'~ , :~~~
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09;
Pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
,~ r b
his schedule must be completed and filed if the answer to any of quest' s 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLEI
TAXABLE
VALUE
~. ~~ ~ ~z,ti~ i fG, C ;• ~,;~ r~ .~ ~~jl~ .~~_~
~' iii, ~ ~ ~~ et `,~ /, ~s_-~
~~~~,,~,~,,~i b ~ ~ril~, ~~.1v, s ~n ~ N~
~.- ,
{ ~ /
~ l"
c'
,,
~•
r
c- ,
TOTAL (Also enter on Line 7, Recapitulation;) $ 'f/ /~~' ~•00
If more space is needed, use additional sheets of paper of the same size.
REV-1511 Ex+ (10-09)
pennsytvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
,~.'
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
Decedent's debts must b~eported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. ~ ~ j
z ~~ ~ .
~ ~~ ~„~ mss::. `1~~ ~~~- Cep~~ ~ ~'~'` /G'd , t~t~
1 <~ ~ 'J
~~
_ ~ r ~une r,` ~~f .75~
~~~) L~ Y 1 nc. /~ L ~~ C, l i e n n ~ zif v~'~ ~
s c2 d,~ <' ~ Jac v) /~E'~11 c ~~ c. -~, .L, i1 ` . ~ v ~ yr
~_~
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) 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: ~~ 9j ~-~
S• Accountant Fees:
6. Tax Return Preparer Fees: j j ~ ~ !~
(~
7. m, /~e...~;~ [',~~~'/r„Sc'- ~D IYI~SR'--~°~~ n ec~:'.SSs~._~y ~~.~S,rle.sr ~~,n`~~ ~,
T
¢ //~~ ~ (?
1-en`1= Y
~ :~ ~ C'' e c~>Fi•) -~ ~~s ~j SSr'3 ; n » s ~o .'rt ~2~iy~
, ~ /I ~ti / ~ 1~rI
l r
f'-d-S ~I / [ rn .,fJ / ~ /Yl L ~ `~ ~?r//j1j ~
r, T~
c1 r ,--
f
~/'
UU ~/~ T~
~?
/~ ~
-•'~' /~';~ ,p l Y l ~~Gt- i r'- /3 / ' ssr~.-l i ~i ~.' C` .~ Q eS L-~c'1 ~~ _5 ~9 C'~ -, /
/ L~ L~ , ~ C~
TOTAL (Also enter on Line 9, Recapitulation) $ "T ~ ~~ Z~
If more space is needed, use additional sheets of paper of the same size.
REV :5':[ E. k. ~ i'.°',
pennsytvania
L`l DEPARTMENT OF REVENUE
INHERirANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF ~ _ FILE NUMBER
2 r ~~ a~ _ GZ m ~2 ec.. ~
Report debts incurred by the decedent prior to death that remained unpa at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER nDESCRIPTION OF DEATH
~ ~~
/~
~_~
~, ~ j ~~~ ~~ L' ~L S ~
/• f
~'~~ ~~ C.~ }--~~
~ ~~:~ 1~ I~
d ~ i1'h'~ Sri C4~
~~
~k~,~~
;~ ~a~~7
~~
«....-
/t rn ! C"~ ~j
/_'~,~~~
TOTAL (Also enter on Line 10, Recapitulation) I # ~~~~~ ~ ~~ J'~
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
SCHEDULE 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
Sec. 9116 (a) (1.2)]
1. _
J ~c>/ h ~ ~ E' h ~'~1'1 S
~ l ~ ~f'/r
z
,--~
r ~~ `~~l ~ :~~`~ ~~ ~-l' n
'l t ~ ~ a ~~- -~ b ~ .,~ ~
~ v'Id\ 73 rte' ~,- //
/
~
~ i~
r 11 l(/~
/
( 1
~j //
=d~ ~n , /~~ ~
/ ~ / ~ ~/ /~J i
c
~ .
-
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II
1. 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
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)