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Home My WebLink About09-18-12J 1505610101 REV-1500 Ex ~°1.1°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes °EPARTME"T°FAE~E"~E County Code Year PO BOx 280601 INHERITANCE TAX RETURN ~) j Harrisburg, PA 1128-0601 RESIDENT DECEDENT / / , ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~~~/ ~.3 .~~ 4,x''1 ~~ _y~ ~ ~ Decedent s Last Name Suffix Decedents First Name (If Applicabl )Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI MI FILL IN APPROPRIATE OVALS BELOW 1. Original Return ® 2. Supplemental Return p 3. Remainder Return (date of death prior to 12-13-82) p 4. Limited Estate p 4a. Future Interest Compromise (date of p 5. Federal Estate Tax Return Required death after 12-12-82) p 6. Decedent Died Testate p 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 p 10. Spousal Poverty Credit (date of death Q 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 REGISTER OF WILLS USE ONLY ±~.~ r~ t0! ~- ~ ~~. cr - ~ ~ C'?~ - ~ ~ FILED ..,.: , ._ First line of address Second line of address / City or Post Office State ZIP Code r`,~~ --- -rt ~~ ~ IRy Correspondent's a-mail address: ~ • ~ ~ ~ ~ Under penalties of perjury, I declare that I ha a 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 RETURN ESS i File Number DATE SIGNATURE OF PREPARER OTHER THAN REPRESEI~ATIVE ~ DA' ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101, 1505610101 J h~ J REV-1500 EX Decedent's Name: //' D/"~~/~ ~ ~ /l ~' 1,50561,01,D5 Decedent's Social Security Number ~~~ /~ ~3~3C~ 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. 9 9 ( ) ........................... Mort a es and Notes Receivable Schedule D 4• • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E). • ...... 5. • 6. ..~ Jointly Owned Property (Schedule F) ® eparate Billing Requested . t P t P b ...... 6. ~ ~ (~ ~ • ~ r 7. roper y e ro a Inter-Vivos Transfers & Miscellaneous Non- (Schedule G) O Separate Billing Requested.. ...... 7. • 8. ( g ) ................ Total Gross Assets totalLines1throu h7 ••••••• •••••• 8•, ~ ~ R 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. ~ ~, ~ ~f • 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ ...... 10. • 11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. • ~~ / % / 1 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 1 _J I ~ • ,~ / { ~" 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. ~ j} ~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 _ j~ . f '~ 16. .--~ ~ • 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 TAX DUE .................................................... ..... 19. ~i1. .~ "( ~` . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1503 EX+ (6-98) ;~ ~ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN ESTATE OF , FILE NUMBER All property j6intly-owned with right of survivorship must be disclosed on 5cnedule r. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. t ~~~ ~ ~ ~ ~ ~'~'iG~' ~~r~ ~~G~rU C~~J ~5"-Jy- ,~~/~ ~~~~ ~tv~~C~. C r~s~ ,~~ 7y~ ~~ ~ ~~~ c'~«p~~ ~` - ~~'l~ct~C~'I~iIZ 1 ~iI~~~YIGI~.C I ~~11 ~., TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-i5og EX+ (oi-lo) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDVLE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: d ~ If an asset became jointly owned w' in one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. ,~-- ~-~~i~ .~ .~ ~ ~ B C JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY ELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~!/°~ 11;1 `} ~ ~ L' ~= L`~ !i'.~. ~ ~J ~ T < - ~O ` `1~ " ~ ~ ~ r ~.J ~ 1 ~ ~ ~ ~l~ J TOTAL (Also enter on Line 6, Recapitulation) I $ ~ ~ ~~~ ~~ ~~ r' If more space is needed, use additional sheets of paper of the same size. REV~1513 EX+ (11-08} ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF FILE NUMBER NUMBER I 1. II NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] ~ 9 ,~ ~~ Gc;~ /t~l r~- ~~ .~ y ~~ ~~ RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE ~.~ ~ / l.~h~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 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-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME p,,, STREET ADDRESS h CITY ~ r / --~,v7.-~ ~ i_ ~_ .,. , _ - a° l,. , ;n ,-I File Number - i 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) (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 ^ No a. retain the use or income of the property transferred :.................................................................................... retain the right to designate who shall use the property transferred or its income : ...................................... b ...... ...... ^ . . ^ ~ 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? ....................................................................................................... ^ ....... ~-f L'J death? h t hi i ^ ....... er s or ty a 3. Did decedent own an "in trust for" or payable-upon-death bank account or secur ....... 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. ~~~ ~~ ~ ~~ ~~ ~a ui 0 .~, n ~~ ~~ ~ ~ ~ ~ ~, , o ~ m ~ ~ ~ D ~ ^^ ~ ~ ~ o c (~ '~~° :: IN o '; ~ x" ~ ~ w fD a. o °"~ w o ~ ~ m ~ ~ a' ~ ~ o' ® ~ o 'Y ~ ~" N ~' ~` fit qq~ C-Y b "Y .-' ~. ~' " ' ~7 ~ ... --'~€ ~ ~~ ...,~ .r --~{ ~ ~+ d~'i ~ _~ ~" ®Y ~ ~ ~~~ ~' f. a ., u n Cff'7i ,: ~~~~ ~~ I .~~~~~ .. ~'S ,. ..~ ~~ '~ _, ~ -Y.~ ~,