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Home My WebLink About10-29-12 (2) 1505610105 REV-1500 EX (oza l) (Fl7 PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of lndividuat Taxes PO BOX 28D601 `~"'" "° Count Code Year File Number INHERITANCE TAX RETURN nn ~ ~ U IC ~ Harrisburg,. PA 1'7328-06Di RESIDENT DECEDENT o ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Dea[h MMDDYYVY Date of Birth MMUDYYYY ,via oai siq;3e Decedent's Last Name Suffix Decedent's First Name MI ~/~~-VE2T ,TO A"N (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 INAPPROPRIATE OVALS BELOW O 1. Original Return O 2. Supplemental Return O 3. Flemainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Fetleral Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust S. Total Number o(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 1-1-96) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~: r NI P A'7''T E2S ~~ r.~ r, <-:, First Line of Address I ~a ~o~A-~ Second Line of Address City or Post Office Di LLS3 ~r~ RIEGISTER OF WIL ONLY ~ ~,"~~ ~~ ~ rTt T, l 1: ".', r C ~: G I1 ~ 0 _ r „, (J+ ~~ 1. _r. 0~ cyy~~T '-T DATE FILED - ~~ State ZIP Code _ ~A"' ~ -]c~ ~.5 Correapontlent's a-mall address: Under penalties of perjury, 1 declare that I have examined this return, inclutling accompanying schetlules antl statements, and to the bast of my knowledge and belief, it is We, correct and complete. Declaration of preperer other than the personal represenlalive is basetl on all in(armation of which preparer has any knowledge. SIGNAjC~'OFtiR,StON RESP~'](JSIBLE, OR FILINGV~RN /~ DATE AD-DJTR/ESS ~iJQ-t"~r'7^'> 7 O~ (~ SIGNATURE OF PREPARER OTNiER THAN REPRESENTATIVE DATE ADDRESS PLEASE U8E ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J a 150561205 REV-1500 EX (FI) Decedent's Social Secudty Number Decedent's Name: RECAPITULATION 1. Real Estate (Schedule A)......... _ .................................. L 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corpora ion, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Depositsand Miscellaneous Personal Property (Schedule E)....... 5. y O ~. t. q ~ ~ + 70 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. B. Total Gross Assets (total Lines 1 through 7) ....................... ...... 8. 9. Funeral Expenses antl Administrative Costs (Schedule H) ............. ...... 9. , ~ 5 S ~ a 3 10. Debts of DecetlenL Mortgage Liabilities and Liens (Schedule 1) ......... ...... 10. 4 ~ y'6 ' 3 11. Total Deductions (fatal Lines 9 and 10) ........................... ...... 11. '. "7 {,.~ (~ ~ 1 3 12. Net Value of Estate (Line 8 minus Line 11) .......... ............ ...... 12 L 3 Q 3 SyO 3`f 13. Charitable and Governmental Bequests/Sec 91i3 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. TAX CALCULATION • SSE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tex rate, or transfers under Sea 9116 (a)(1.2) X .0_ 75. 16. Amount of Line 14 taxable at lineal rate X .0 ~ I, a (p ~ ,S 7 16. 17. Amount of Line 14 taxable ~ 'r ai sibling rate X .12 17. 18. Amount of line 14 taxable at wllateral rate X .15 18. 19. TAX DUE ................................ ........ ... ... ........ ... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 383 59~.3y 1 ~y o~V ~. s~__ O Side 2 1505610205 15[75610205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (i) ' / - ~ ~ ~ C - 2. Credits/Payments ~ A. Prior Payments _ B. Discount Total Credits (A+ B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 + Lime 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to'request a refund. (4) 5. If Line 1 + Line 3 is greater than Lime 2, enter the difference. This is the TAx DUE. (5) ` ~ , 1 (O ~ , S 'Make check payable to: REGISTER OF WILLS, AGEIVT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent mane a transfer and: Yes No a. retain the use qr income of the property transferred ................................................................................... ....... ^ B' b. retain the rightl to designate who shall use the property transferred or its income ................._._..._.......... ....... ^ c. retain a reversionary interest ....................................................................................................................... ....... ^ d. receive the prmmise 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 dequate consideration? ....................................................................................................... 9 l l ....... ^ owrl an "in trust for" orpayable-upon-death bank account or security at his or her death? ....... 3. D d deceden t ....... ^ IJ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefrriary designation7 ........................._..._......................._..........._......................:.................... ....... ^ 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 dales 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)j. The statue 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 benefciary. For dates of death on or alter 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 pera;nt, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net 4alue 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. AEV-1508 ~+ (OS-12) pennsytvania SClIEDULE E Y7 OEPARI'MENTOFREVENUE CASNr BANK DEPOSITS & MISC. INHERII'gNCE TAX RETURN PERSONAL PROPERTY RESIDENT pECEDENT ESTATE OF: /+ FILE NUMBER: Igclude the proceeds of litigation and the date the proceeds were received by the estate. All grocerty iointly owned with right of survivorship must be disclosed on Schedule F. ITEM ,. Usa~ svgs ~c.c_~ oa-+~~-v~~--~ oZ• U J A•K}- f u5S (~-c.c..~ vua4d' - `1JSY • 3 J, H ~vnh.4•t ~ J~ ~' e c.c s. 3 ~~ xxxx x s- ~; ~ 4 ZK~- Xxxx.X ' ~~r ~~. s~ /~57. 17 /~6~, S3 (prQ, UJ 137a~~ s~ a~o~ a~a, sz~ TOTAL (Also enter on Line 5, Recapitulation) ; y [f more space is needed, use additional sheets of paper of the same size. ?~ ,REV-1511E%+ (10-tl9) ~ Pennsylvania SCHEDULE H De.RnRrmENT ov RevarvuE FUNERAL EXPENSES AND '"NER°""ceT"xRET°"" ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF P //11 FILE NUMBE C Y1 C (,/~~1/t/~ Decedent's debts must be reported on Schedule 7. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. C v e r. ~ r'h Fu r-.~.GI..Q hL eiYY7J/ ~ 'tom fu'Yctc l~ a it.. z' S c /h ~ , a.0 ~.~•..ta~ e. ADMINISTRATIVE CASTS: L Personal Representytive Commissions: Name(s) of personal Representative(s) Street Address _.. City. _..____._._- _. ......State. ZIP Year(s) Com~hission Paid: __ 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant -_... Street Addre45 _____ CitY_ _.__ _ _.. .......... ....State.. .._ZIP __..... ._..__-__. Relationship bf Claimant to Decedent 4. Probate Fees: I, B~ Accountant Fees: ' / l 6. Tax Return Prepared Fees: f ~~.t L1 r(,.~-~„t/t r1 J '. lll...... TOTAL (Also enter on Line 9, Recapitulation) ; R AMOUNT 530 ~i. 9Y l,~fy9.3y 4 y~, w 3 q3. ~z~ y~i.s"3 If more space is needed, use additional sheets of paper of the same size. rg. ~3 REV-1512 EX+ (12-OB) ~ Pennsylvania SCHEDULE I DEVARTMENT OF REVENUE DEBTS OF DECEDENT, '""ER'T""cE TAx RETUR" MORTGAGE LIABILITIES 8t LIENS RESIDENT DECEDENT ESTATE OF ~ ~ ~'~V~ FILE NUMBER o~ f ~-- Report debts Incurred by th! decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. nii unco _____.__._.. VALUE AT DATE 1. COn~-in.,~t`;,.~ C~9-~~. ~,x /vay.9~ ~• M auz 0 ~ ~r. 1JnSr~- X] (, ,S/r!A-'~rnWCi/J) ~ y S.Gv + Mv,K. off- h,~„~,.,h~~i. 9x'd'' y~~. u~ 3 F1 t ~, ~u.-P pJ, I'U ~r~~1 y~~- i z~. f}zt ~lc..h~n 3 . st' P,~~ l~wl ~+ /r rc,. o~ ~~n n U ~ };k,~.r~ a l 4~ L~,nr.~..7 ~f~c dao ~~ ,~ za Llc.ti ~ r-, ~ r 7 y 1-~a ~.~ fp; ~ f 3 ~ ~ ~e~4s~.c K.n.h~.b y,.t.d.,t-.~ G~~ YhL-~d TOTAL (Also enter on Line S0, Recapitulation) I j ~~~~ r3 0.00 If more space is needed, insert additional sheets of [he same size.