HomeMy WebLinkAbout08-28-12 (2)1505610101
REV-1500 ex `°1.1°'
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
oEO.„.„E„. County Code Year File Number
Bureau of Individual Taxes ~ pINHERITANCE TAX RETURN ~,
PO Box z8o6o1 RESIDENT DECEDENT ~ ~ ~ ~ ~ ~ ~ << ~-~
Harrisburg, PA 1'7128-ot3oi
ENTER DECEDENT INFORMATION BELOW a C) jam.
Social Security Number Date of Deat MMDDYYYY Date of Birth ":1P:IDDYYYY
Decedent's Last Name Suffix DecedenCs~First Name M)~
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouses 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)
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)
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 Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
REGIS OF WILLS ONLY ;
First line of address =-'~` "~ -'~ µ-i^
~j - ~ _ ~ J
~./ ~ i CC ' . `~
Second line of address C->~-_ ~` ~ -' <_ ,
~..- ~" r
SDATE FILED ~ ~ -~
City or Post Office to ZIP Code
.~ o ~ ~~- 1 ~ ° ~.S
~~ ~
Correspondent's a-mail address: ~ ~/J C/~ tY3/ I / ~~Qf 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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETUIjgl "~ ~ ` ~ DATE - /
ADDRESS ' ~ /L'~1 C
SIGNATURE OF PREPARER OTHER THAN REP ESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101
J
1505610105
REV-1500 EX
D/ece/d~,ent's Social Secur/it/y' NumbJer
Decedent's Name: ( ~ ~~~' `Q,~ C
RECAPITULATION 1~ ~/~~1 ~~ll
1. Real Estate (Schedule A) ........................:.... °....:.......... ` 1. l ~ ~ ~ G ~ ~LJ V
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. ' ~ I~ 3 ~ . / `9
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6. ' • f
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) p Separate Billing Requested........ 7. R
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ ~' ~ 4~ /~ .
9. Funeral Expenses and Administrative Costs (Schedule H) ~
.................. 9. ~ ~ 3 ~~~-s
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ~ ~~ ~/ ~~ . ~/
11. Total Deductions total Lines 9 and 10 ................................. 11. ~ • d ,
. ,.. L ;
12. Net Value of Estate {Line 8 minus Line 11) .............................. 12. ~ 3 ~ (~ r
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. ] ~ ( 2 ^~ ~ .~
.)
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount cf Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 t~x~le _
at lineal rate X . . 16. (,: ~x 6 ~ '. ~~
17. Amount of Line 14 taxable k ~ ~ s " ~
at sibling rate X .12 . 17. '.
18. Amount of Line 14 taxable ~ ~ ` ~ ~ ~ `'~ r ~ ~ '" ' r '~ ' '` `~, '~~ "'
at collateral rate X .15 ~ 18 - F
_ ... .. ._ r~-.~~~~ , ~~< o
19. TAX DUE .........................................................19. ~ , ~ --..
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610105 1505610105 J
REV-1500 EX Page 3
Decedent's Complete Address: /~
File Number
DECEDENTS NAME ~~ ~ I-') (• ~ r~
STREET ADDRESS
-- --- -
CITY ~ ^ ~, l ~ --- --- STATE ~D -- - ' 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)
(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 N
o
/
a. retain the use or income of the property transferred :.................................................................................... ...... ^ ,
~
,
lt
J
'/
b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ ~
,
L~
J
'/
c. retain a reversionary interest; or .................................................................................................................... ...... ^ ~
-
,
is
X/
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ ^
Ld
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 "intrust 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-1502 EX+ (11-08)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
REV-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX+ (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
FILE NUMBER
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
(If more space is needed, insert additional sheets of the same size)
REV-1505 EX+ (6-98)Y Y ~ SCI~IEDULE C-1
CLOSELY-HELD CORPORATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN STOCK INFORMATION REPORT
RESIDENT DECEDENT
~~'/P
ESTATE OF FILE NUMBER
1. Name of Corporation State on Incorporation
Address Date of Incorporation
City State Zip Code Total Number of Shareholders
2. Federal Employer I.D. Number Business Reporting Year
3. Type of Business Product/Senrice
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK VotinglNon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common ~
Preferred ~
Provide all rights and restrictions pretaining to each class of stock.
5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes
If yes, Cash Surrender Value $ Net proceeds payable $_
Owner of the policy __
8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years
if the date of death was prior to 12-31-82?
^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No
If yes, provide a copy of the agreement.
10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
• • •- ~ ~ ~
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
^ No
(If more space is needed, insert additional sheets of the same size)
REV-1506 EX+ (9-00)
SCHEDULE C-Z
COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP U "
INHERITANCE TAX RETURN INFORMATION REPORT
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
1. Name of Partnership Date Business Commenced
Address Business Reporting Year
City State Zip Code
2. Federal Employer I.D. Number
3. Type of Business ProducUService
4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $
5.
PARTNER NAME PERCENT
OF INCOME PERCENT
OF OWNERSHtP BAWNCE OF
CAPITAL ACCOUNT
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No
If yes, provide a copy of the agreement.
11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-1507 EX+ (1-97)
~~~ , SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+11-97)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA 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 jointlyowned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
~~~~ ~
VJv ~5i ~
11 ~ ~ 3K'`~
TOTAL (Also enter on line 5, Recapitulation) I $ ~~f,~ ~~ , ~~
(If more space is needed, insert additional sheets of the same size) L 6~
REV-1509 EX+(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE F
JOINTLY-OWNED PROPERTY
"~,~
FILE NUMBER
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
JOINTLY-OWNED PROPERTY:
ADDRESS
RELATIONSHIP TO DECEDENT
LETTER DATE DESCRIPTION OF PROPERTY
ITEM
NUMBER
FOR JOINT
TENANT
MADE
JOINT
Include name of financial institution and bank account number or similar identifying number. Attach
deed for jointly-held real estate.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) I $
(If more space Is needed, Insert addltlonal sheets of the same size)
REV-1511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCNEDtILE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
~ ILL I~VIYI~Gf1
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: i b~ j
1.
~n~'~~ ~ b~~ y
B.
1
Year(s) Commission Paid
State
2~ Attorney Fees
3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
4• Probate Fees
5• Accountant's fees
6• Tax Return Preparer's Fees
~. ~~~~
~~~k~n ~~
. ~~~n
~-~~~ b~~
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) _
Street Address __
City
Zip
Zip
~~;y,~
~y~ ~v
~~So.~3
~ 1~~ , ~
~'~~ ~ ~~
~' 3~S- ~ v
TOTAL (Also enter on line 9, Recapitulation) $ ~ . S3
(If more space is needed, insert additional sheets of the same size)
~~dc~~~-~~ ~~~~
C~~2m~ n ~`~~
c~F~~ l ~~u~~l ~~y .
U `"
Lawn ~=
b~rn~ s~
~y~~~~ °~
~ 3~, 3~ ~1
A. SETTLEMENT STATEMENT (HUD-1) r rrt
°s~, I. ® FHA
` 4. ^ VA
~~ '` `q~ 6. FILE NUMBER:
,`6 ; r~ 12-00170-ALT
No.
I RHS 3. ~'~_ ~ CONY. UNINS.
CON V. INS.
/. LUAN NUMBER
""'" 8. MORTGAGE INS. CASE NO.: 446-1363066-703
C. NOTE: This form is famished to give you a statement of actual senlement costs. Amounts paid to and by the settlement agent aze shown. Items
marked "( ,o.c. "were aid outside the closing; they are shown here for informatronal u oses and are not included in the totals.
D. NAME & ADDRESS Bonnie L. Bellis
OF BORRO WER: 211 N. 6th Street New ort, PA 17074
E. NAME & ADDRESS Estate Of Leroy Boyer
OF SELLER: 615 B Street, Enola, PA 17025
F. NAME & ADDRESS Wells Fargo Ban]:, N.A,
OF LENDER: 2701 Wells Far o Wa , Minnea olis, MN 55408
G. PROPERTY LOCATION: 615 B Street, Enola, PA 17025
H. SETTLEMENT AGENT: .Assured Land Transfers, Inc.
PLACE OF SETTLEMENT: 301 Market Stree Lemo ne PA 17043 717 761-4720
I. SETTLEMENT DATE: 8/18/2012 CLOSING DATE: 8!15/2012
J. R.. ..ou,.. i _
_________ ____-.,,,,_,,,
100. Gross Amount Due From Borrower: x. Summa of Seller's Transaction
400. Grass Amount Due To Seller:
]Ul. Contractsalesprice 136000.0 0 401. Contract sales rice
102. Personal property
402. Personal roperty -_ 136.000 00
103. Settlement charges [o borrower: (line 1400) 5 283
1 3 403.
104.
105 .
404.
. 405.
Adjustments For Items Paid B Seller In Advan ce: Adjustments For Item
P
id B
106. City/town taxes to s
a
Seller In Ad vance:
406. City/town taxes to
107. County taxes O8/IS/12 to 12/31/12
108. Assessments to 182.0 1 407. Coon taxes 08/15/12 to 12/31/12
182
01)
109
S
7/ 408. Assessments
to '
.
ewer
8/9 8!15/2012 [0 9/3011012 66.29 409. Sewer 7/8/9 8/1512012 to 9/30/2012
110. School Taxes 8!(52012 to 6/302013
1 360.51
410. School Taxes 8/15/2012 to 6/30/2013 66.29
111. 411. - 1 360.51
112.
412.
113.
413.
114.
414.
-
115. 415.
116. 416.
120. Gross Amount Due From Borrower: 142,891.94 420. Gross Amount Due To Seller:
2 0. n P id alf Of w r:
0 ti ns In Amoun eller: 137,608.81
201. Deposit or earnest money 1 000.00 501. Excess deposit (see instructions
202. Principal amotmt of new loan(s) 133 536.00 502. Settlement charges to seller Qine 1400) ~ --
`
203. Existing loan(s) taken subject to - -
503. Existing loan s taken subject to I ~~
.83
_x
204. Lender Credit 0.66 504. Payoff 1st Mtg. Ln. -
205. 505. Pa off 2nd Mtg.Ln.
206. Seller To Buyer Assistance 4 900.00 506. Seller To Buyer Assistance
207.
507. Earnest Money hcld by broker 4 900.00
208'
508. 1 000.00
209' 509.
Adjustments For Items Unpaid By Seller: Adjustments For Items Unpaid B
Seller
210. City/town taxes to y
:
S I U. City/town taxes to
211. County taxes to
511. County taxes to -
212. Assessments to
213 512. Assessments to ~~ `
. 513. -
214.
2]>
514.
-
. 515.
216. 516.
217. 517.
218. 518.
219. _ 519. ----
220
T
t
l P
id B
/
.
o
a
a
y
For
Borrower:
139,436.66 520. Total Reductions
30 h In Amount Due Seller: 22,750.83
At S t Fro r owe ash n Fr
301. Gross amount due from borrower (line 120) 142 891.94 601. Gtoss amount due to seller (line 420)
302. Less amount paid by/for borrower (line 220
)
139 436.66 6 137 608.81
02. Less reductions in amount due seller (line 520)
303. Cash {FROM) ~^TO) Borrower.
3,455.28 6 22,750.83
03
Cash (~fTO) (^FROM
.
) Seller: 114,857.98
The Public Reporting Burden for [his collection of information is e stimated at'ts mGm~rP~ na . ~o~,.,...~_ a.,_ __~~__.:__ ____~ _.
may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control numbe~rtNo confidenti Ihty 9sassured;
this disclosure is mandatory. This is designed to provide the paRies to a RESPA covered transaction with information doting the settlement process.
X X X X
Previous editions are obsolete Page 1 of 4
HUD-1
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
t.
~~-~ ~3
~ ~--
1 ~ .~ ~
1 ~ ~ ~o . ~o
~~ ~~~.1~c~ ~- ov
1 ~~
~,k~~~3
TOTAL (Also enter on line 10, Recapitulation) $ I ~ 7
(If more space is needed, insert additional sheets of the same size)
U M~'~~
ACCOUNT PAGE
000000010633553 3 OF 3
LEROY P YOYER ~°121 1.573
ens a m.
ENOtl~ PA 1 7 02516 0 2 ~i
d~
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PAl'TOSAE ~ I
D ^
/~1M&TBank DOLLARS 8 ~~,"
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30633553~~;573
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e1s a sr.
ENOLA, PA 1702}1602 ~ -, /
LCI ~~ l J c, nnt~ ea"~
out o~ E ~/ r.~ ('~C~f~ rc~ I C
~Y $ fC~J
I [ L~ C~ d I G~ -' DOLLARS u GY`,
~ I~51M&TDank rt^
1:0333029551: i0633553i~~575
Check It1573 Paid :09/01/4019 '~
_____ ;56D.00 Check 1{1575 Paid :04/15/7019
;105.00
tFROV P eoYER g.2, 1578
e1b 8 6T.
ONOl.1. Ph 1702S16Ye ~~ ~- I~
PAY TO ITt[ ~ f^
1,.1 2 1.'~Ir' L..tC~ ~ ~lJl ~~C 'PDOLLnRS[~ $~.""~,'
~Ma7T'Danlc ~
.,..,,.P.,a.
r'~,(
PP~~t~.M.%2
-+:D3 1 30 29 551: i06335531'i548 ~`
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Check It1578 Paid :03/94/4019 ;1lI00.00
REV-1513 EX+ (11-08)
~ Pennsylvania SCHEDULE ,7
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
~~~hi~ yr
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 2116 (a) (1.2).j
~. ~ic~}~I~ ~i~c~~=
437 c~a~~1r,~~ ~~~E
~~~~ P~ 17~~s
~~vf;,~;~ ~B
~~7 ~ S-IrEr~
c`nl~ ~~ I~~S
FILE NUMBER
AMOUNT OR SHARE
OF ESTATE
~-~I s~~
o..~-~r
~~~
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I$
If more space is needed, insert additional sheets of the same size.
REV-1514 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
heck Box 4 on REV-1500 Cover SheE
FILE NUMBER
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
^ Will ^ Intervivos Deed of Trust ^ Other
NAME(S) OF LIFE TENANTS} DATE OF BfRTN •
NEAREST AGE AT
DATE OF DEATH
TERM OF YEARS
LIFE €STATE IS PAYABLE
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Life or ^ Term of Years
1. Value of fund from which life estate is payable ..........................................$
2. Actuarial factor per appropriate table ................................................ .
Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
NAME(S) OF LIFE ANNUITANT(S)
DATE OF BIRTH •
NEAREST AGE AT
DATE OF DEATH.
TERM OF YEARS
ANNUITY IS PAYABLE
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Life or ^ Term of Years
^ Life or ^ Term of Years
1. Value of fund from which annuity is payable ............................................$
2. Check appropriate block below and enter corresponding (number) ......................... .
Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12)
^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ Other ( )
3. Amount of payout per period ........................................................$
4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. .
5. Annuity Factor (see instructions)
Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate
6. Adjustment Factor (see instructions) ................................................. .
7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 ..................................................$
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
REV-1644 EX + (3-04)
I.
INHERITANCE TAX
SCHEDULE L
COM NOHER TANCEOTAX RETURNANIA REMAINDER PREPAYMENT
RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER
NI k
wir+~c yr
~~asi rvame~
(First Name)
(Middle Initiall
I nis scnetlule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of
Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust nrincioal
II.
A. Election to prepay filed with the Register of Wills on
(Date)
B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) of election or annuity is payable
C. Assets: Complete Schedule L-1
1. Real Estate ...............................$
2. Stocks and Bonds ..........................$
3. Closely Held Stock/Partnership ...............$
4. Mortgages and Notes .......................$
5. Cash/Misc. Personal Property ................$
6. Total from Schedule L-1 .................................... ..................$
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities ...........................$
2. Unpaid Bequests ...........................$
3. Value of Unincludable Assets .................$
4. Total from Schedule L-2 ..................................... .................$
E. Total Value of trust assets (Line C-6 minus Line D-4) ................ .................$
F. Remainder factor (see Table I or Table II in Instruction Booklet) ........ ................ .
G. Taxable Remainder value (Line E x Line F) ........................ .................$
(Also enter on Line 7, Recapitulation) _
III. INVASION OF CORPUS:
A. Invasion of corpus
(Month, Day, Year)
B. Name(s) of Life Tenant(s) Date of Birth
or Annuitant(s) Age on date Term of years income
corpus or annuity is payable
consumed
C. Corpus consumed ........................................... .................$
D. Remainder factor (see Table I or Table II in Instruction Booklet) ........ ................ .
E. Taxable value of corpus consumed (Line C x Line D) ................ .................$
(Also enter on Line 7, Recapitulation)
P-EV-lsa5 EX+ (7-85) INHERITANCE TAX
SCHEDULE L-1
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Value
A. Real Estate (please describe)
Total value of real estate $
(include on Section II, Line C-1 on Schedule L)
B. Stocks and Bonds (pleose list)
Total value of stocks and bonds $
(include on Section II, Line C-2 on Schedule L)
C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2)
(please list)
Total value of Closely Held/Partnership $
(include on Section II, Line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes $
(include on Section II, Line C-4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property $
(include on Section II, Line C-5 on Schedule L)
III. TOTAL (Also enter on Section II, Line C-b on Schedule L) $
(If more space is needed, attach additional 8'/s x 11 sheets.)
REV-1646 EX+ (3.84)
~'
CJMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION
-CREDITS- FILE NUMBER
~~i~
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Amount
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L-1 (please list)
Total unpaid liabilities $
(include on Section II, Line D-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list)
Total unpaid bequests $
(include on Section II, Line D-2 on Schedule L)
C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets $
(include on Section II, Line D-3 on Schedule L)
III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $
(If more space is needed, attach additional 8'/s x 11 sheets.)
REV-1647 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
t51AlE OF
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev-1500 Cover Sheet
FILE NUMBER
~j~
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
^ Will ^ Trust ^ Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedents death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
^ Unlimited right of withdrawal ^ Limited right of withdrawal
III. Explanation of Compromise Offer:
iV I Summ~~~. of l~.......-~~:__
1. Amount of Future Interest ....................................................... .
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) ......$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One ^ 6%, ^ 3%, ^ 0% ......................$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One ^ 6%, ^ 4.5% ..... $
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ......$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) ......$
7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .
tir more space is needed, insert additional sheets of the same size)