HomeMy WebLinkAbout08-14-12 (2)P~~V-15 iSOSCG4 -
epartment of 0 ® 112 5
Bureau of IndividuaRTvenue EX (06 05)
PO 80X 280601 axes
ENT Harrisbur
ER DEC ~ PA 17128-0601 INHE'R~T OFFICIq~ usE DNLY
Social SecunEDENT INFpRMgTION gELO ANCE T Coun
Y Number ~, RESIDENT CED ETURN ty Code Year
~- h
~' Date o f p DE EN7 2 1 File Number
1 2 ~ ~ ~ ~~ eath
Decedent's fast Nam O S 1 O 1 1 3
Date of Birth ~-.--~'
C R e 3 1 0 1 0
A I G
l 2
llf q Suffix 0 3 1 9 1
Aplicable) Enter Su DeCedent's 7
SpOUSe's Last Name rviving SpoUSe,s Information E V E FI rst Name
Below L' Y N Mr
Spouse's So Suffix c{
slat Security Number Spouse's First Na
me
FILL IN APP MI
ROPRIATE THIS RETURN
~. Original R OVgLS BELOW RE MUST BE FILED
eturn G[grER OF. I~i~PLICgTE
~$ WITH THE
4 Limited Estate 2~ Suppleme
ntal Return
6 Decedent ~ 4a. Future Interes `--~ 3~ Re
(Attach CoDled Testate t Com mainder Return
pY of Q death after promise prior to 12_ (date of death
9. Liti Will) ~-_1 7, Decedent 12-12-82) (date of ~ 13-82)
gation Proceeds Received (Attach Copy Iofalned a Living Trus 5~ Federal
t Estate Tax Return Re
~ORRESP ~ ~~ Spousal P Trust) 8. Total Num quired
ONOENT . oved 'y-
Name THIS SECTION MUST $E CpMFLETE etween 12-31 91 dt ~ da 95 f death ^ 11 ber of Safe peposit Boxes
L D. ) Election to tax
FIW I L I A M P ALL CORRESPONDENCE AND CpN (Attach Sch. 0 under Sec. 9113(q
rr-rI Na D ~ U FIDENTIAL TAX INFpRMATION SNOU )
me (If Applicable) G L ~]
~ ~ CI G S Daytime Telephone Nu LD BE DIRECTED Tq;
L A S ~ tuber
First line I' A W E 1 7 2
of address F F I 4 3 1 ~~~ 9~
4 C E
_ _---_
3 W !- - ---<-- ..~.. ~-
s' ~ U REGISTER - - _ -- +~,;, ~.7
Second tine of T H s T LS usE - _ -.~-? ,~-_•-;
address R E E T I ~~ f: Y ~~-:'
,.. ,
City or i ~ c,1 ~.. ,l .. ,-:
Post 0 ce ~ f-~-
ffi C) ~--. '
-.
C A ~ ~~ n ~ .~; ,-,
State -~, ~ ~`;~ : r :_ , , .~
ZIP code I ::?~ v..t ; ~,, ~
Corres P A ~ ---__ DATE FILED C': -~'
pondent's __- -
-mail a ~ ----
ddress; 1 _ ___ - -
Underpenalties of per 3 -~
it is true Jury, I declare that I have e
correct and complete
IGNq UR claration of r mined this return, includin
F PERS p parer other than the g accompanyin
PD SIBLE R FILIN Personal representative 13CheduleS and
ADDRESS ~ RETURN based statements, and to the
_.~...;_,` on all information of which best of
preparer has an °wledge and belief,
SIGNgTURE Y knowledge,
ADpRE OF PREPgRER OTHER THAN REP ~ a.,` D T
SS SENTgTIVE ~. .~-..
~.-..
PLEASE US
E ORIGINgL Rp M ON
----~ 15 0 5 6 0 4112 5 Side ~
DgTE
15056041~~~
J
REV-150p Ex
X5056042126
RECgpIT-..,,~ ~ Name: EVEL yN
U~ATI pN K .
CRA I G
1 ~ Real estate (Schedule A
2. Stocks and Bon ) ' • ' ' ~ • .. _`~---~
ds (Schedule B) ~ • ~ ' .
3. CloselYHeldCor ~~~...,, '~~~•.
poration, partn • ' ' ~ ~ .. , ~ 1
4• Mortgages & Notes Rec ership or Sole-Pr ~ ~ ~ ' ~ • ~ • . .
oprietorshi ~ 2.
5. Cash, Bank Deposi eivable (Schedule p) p (Schedule C) ..... 3.
is & Miscellane pus Personal
6. Jointlyp~,~, ~~~''~~••..
7• Inter-Vivos T ~ Property (Schedule Prope~Y (Schedule E • • 4•
(Schedule G ansfers & Miscellaneo) ) .. .
) us Non-P oeparate Billing Re 5,
8. Total Gro bate Property quested ....... 6.
ss Assets (total ~ Separate Billing Re
9. Lines 1-7) quested .
Funeral Expenses • • .. ~ ~ ' ~ ~ 7.
& Administrative Costs (Sch
10~ Debts of Decedent, ~ .... • . .
edule H) 8.
11. Total pe Mortgage Liabilities, & Liens ' ' ~ ~ • .
ductions (Sche • ' ~ 9.
(total Lines Jule 1)
12~NetValue 9&10) ~''~~~~..
13. °f Estate ~~... '~~ 10.
Charitable and (Line g mina ~ ~ ~ • ' '
an election to taGhas note s Line 11) • ~ ~ .... , . .
ntal ge ~ ~ 11.
14. been inquests/Sec 9113 ... • . .
Net Value Sublect t ade (Schedule J) T rusts for which ~ ~ ' ~ ' • • 12.
oT
SgXq ~ouPUTATIpN - SE ax (Line 12 minus Line 13 ' ' ' ~ ~ ~ .. 13.
NS
at the s t of line 14 taxable TRUCTIpNS F ' ' . , .. .
transfer~ousal tax rate • ~ ' ~ • • • .
(a)(1.2 under Sec 91 or ~R gPPLICgg~E RATES ~ • 14'
1g )X.0 16
Amount of L;ne 4
at lineal rate X .0 taxable
17.
Amount of line 14`
at sibling rate X • 1 taxable 15.
18, Amount 2
at collaterf l rate 1X r15 ble
16.
Decedents Social Securit
1 6 4 1 Y Number
2 3 9 9 0
5 0 0 0 0 0
0
5 ~ ~ ~
~ ~ 0
1 6 ~ 0
1 6 6
1 6 0 1 6
3 6
3 2 9 8 3 4
3 3 2 9
8 3 4
19' Tax Due 17,
~•"'~••• 18.
20. FILL IN THE OVgI IF ~ ' ' ' • ~ ~ • . 19 4' 994 ~ 75
YDU ARE REQUESTING A 4
REFUND pFgN oVERPgy , 994.75
MENT
D
15056042126 S'de 2
15056042126
~ced~nt,
°E~EOFrvrS Nq S COmplet,~ A
pE~YN K. rp ~ . _ aar~ss:
_.
_,
ax pa
1, Tax D ,Y11•)ents an __
_.
_-
__
ue _- -
2. Credits/P (Page 2 Mme 1g r~d~ts: ~--
A, S xYments ) ~ ~ ____ _ _
pousal p •, STq TF ~ - -_
~~ Prior p ove,tY Credit _ _ _ _
aYments __.
C~ Discou __ _ _ __
nt ' Z/p
3' Inter
est/Pen
D~ Interest altylfapplicabl
E' Penalty e (1)
4. !f (/ne
2 is 9reater tha
n Line 1 + Total Credits (A +
Fill in ovai on p 9e 2 'enter the di B ~` C
'~ If dine 1 + )
Cine fferenc (2)
3 ~s 9reater ~ Cine 2p to re e, This is the
A. Enter than Llne quest a refund ~~ERP
the interest 2, enter the AYI-gENT Total Interest/Penalt
difference, T . Y (D + E )
B. Enter the °n the tax due. hrs is the T (3)
total of Line 5 f "~ SUE
5A. This is the BALAN (4)
CE SUE (5 ~~-~
/l~a~e the )
p~EASE AN ~~F'a1'abje fo , (5A)
1 • Did dew S MFR rNE F~ ~ REG~Sr~R (5g)
x, retain dentmake a transfe C~Ow~NG Qv ~F~~<<S
the use or income r and ~ EST ~~NS ,g Y p ' AC''ENT
b, retain the
c, retain a reV~9ht to designate the pr°pertY trap IAC~NG AN -- „
d, receive th ersiona who shall use the proed , x ~N TH _
rY inter
2. If death occur epromise for life ° f or pertY transfefr • • • • E APpRO pRIA
with daft either • • • • • ...... ed or its income. • • ~ • T E
3 out receivin er Dec payments • ~ • • • • yes B~ OCKS
ember b
4 Did decedent 9 adequate co 12' 1982, did ' enefi~ts or car ~ .. Q N°
Did decedent ow n an „in trust f sideration~ decedent transfere • Q
or •' Q
contains a benefice' an I ndiv~dual Ret°r payable upon d property within °ne ~ 0
~xrY designation ~ cement Account aeath bank ac~oUnt ....... Year °f death • • • Q
ER T Q ANY pF T nnuitY, or °r securit
'n HE AeO~E QUEST other non probate p obis or her death? • ' • Q
~~ ~ S to ~ my 1, 1gg4 an IONS ~S YES, VQU pedY which Q 0
~ 116 d be fore Janu Q
or after J (a) (1 ~ 1) (~)I. ary 1, 1g MUST OQMPLETE
(ii)), The nuary 1, 1gg5 95, the tax rate i SQHEQUCE G
the
71 applicable etven does not eXemrate imposed on t mposed on the net value ND F~CE ~T AS PA
f the s t a transfer to ~f transfers to
after Jul urvivi he net value of or for th T OF T HE RET(/RN
~he net Vale, 2p~g; n9 spouse is the one urviving sp0usatransfers to or for e use of th
'are e °f transf Y beneficiary, from tax, and th the use of the s e surviving spouse
nt of the child i ers fro e statutor urviving s
'net Value o s Zero (p~ per ent ased child twee _ Y re9uirements ~0use is Zer° 0
~g 116(a)(1)If transfers to or fort l~2 P, S §9116(x) 1ne Years of age °r disclosure of a~ ecent
1 et value o f t he use of the deced (2)~• or younger at death is and
who has at lea tors to or for the u ent s lineal beneficiarie ~ to °r for the use of a na
ne pare se of the de s ~s fo tural parent an
's sib
nt in c°mmon with thedent lings is ur and one-hxlf (4.5) pert
decedent, wh twelve (12) percent ~Z ent, except as noted in
ether by blood or adoptio
r n P,S• §9116(x)(13
)I• A sibling is defined
under
~OMti1o
lNHERITgNTH OF pEN
ESTATE OF RESIDENT DECEdFNTRN ANIq
EVES YN
K CRgIG
ITEM
N~e~
1.
Include
All dr,,.. _ the
cgSy S~HEOv
BgNK CEP CE ~
PERS~Nq ~S~T S, ~
C PRO pER MSC
Ty
v''~m'JOjntly o S oflitigatio~ and _~-
PerSDnal /n~U wned with right o fSUN Vthe prooeeo's F~~E NUMBER
rY UnderinSUr ~ °rship must be re received ~ ~ 33
a~~e re~o~e ES~RIPTION disclosedoySCh~dule
rY from Nationwld F
e
SAC ~E
OF A T oq TE
DEATH
$so, o00 00
(/f more space
is needed, inset additional
she~TAC (Also enter on
ets of the sa I one 5
me sizel ' Re~apitulat~~„ ~
-J y)
COM NHER TAITH OF PENN
RESIDENT pECEDENTRN ANIq
ESTATE OF
EV E~ YN K Cl~,q 1 C~
1 TE~,j
N~MBER
A
1 ~ ' F~NERA~ EXP
ENSES,
F NER E~V~E H
ADININ1-rR~ CSOS S
Debts
of decedent must be reported
°n Schedule
DESCRIPTIpN
F~~ENMEBR
133
AMOUNT
1
ADMINIST~TIVE C
Personal Represen~sve's
Commissions
Name of Personal Representa
Social Sec tive (s)
AddreritY Number(s)~EIN Number of P
Street
ss ersonal Re
City presentative(s)
Year(s) Commission Paid:
Attorney Fees
State
Family Exem ~~ Zip
Pb°n, (If dece
dents address is not the sa
Claimant
StreetAddress me as claimant's, ahach ex 1
p anation)
City
Relationship of Cl .
a~mant to Decedent
Probate Fees State
~`'~ Zip
Accountant's Fees
Tax Return Preparers Fees
Pecs
Filing Fee l nF ry rec
( amity Settlem ee t0 ~cuglas
ent Agmt & Amend Office
ed RetUrn)
$16~ 666, 66
$35, p0
(If more space is needed, inse
T ~TAL (Also
rt additio enter on line 9
nal sheets of the sa
,Recapitulation) $
me size)