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HomeMy WebLinkAbout12-12-12 (2)15056101D1 REV-1500 Ex ~°1.1°' ' OFFICIAL USE ONLY PA Department of Revenue pennsylvania °EPAATMENT°FRE~EN°E County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX28o6o~ ~ r / 10 ~ Harrisburg, PA 1'7128 0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~c~r ~~ ~~~~ ~q~~~ ~ ~~ ~,3~~ ~q~~ Decedent's Last Name Suffix Decedent's First Name MI ~~ r~. oR i~~C~E~.r~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required U 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CCNIVL~ ~ ~R~~t3~~~~ '7~7 `~`~~3~~~0 First line of address X39 Z3R~C~ Second line of address ci~uR c~ Ro~D City or Post Office State Correspondent's a-mail address: ~~ wCi NCB iaiuCS ui Ner~ury, ~ ueciare inat ~ nave examine° tnis return, inciuaing 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. SIG URE OF PERSO RE NSIBLE OR FILI RETURN DATE r/ ~ _ / ~ o A ESS , / _3~' it ~~. L ~,~~sr~ ~ J~ 1 ~l e~ irr l~~- ~I~ l ~~ ~ l SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ISTER Ok:IlVILL9~S6~NLY Q~ ..'T:~ r`*'t ~ ,°t ~,~ :.; ~.. ~ ......y ~,,,.~ r~ ~. I~ ~..-1 1.1.. ~ .A `'; ~ f 1 S `rye-,Y ~ ~ 4 r w ~~ , y ~~ °~ .g ~y'~ DAI~ILEt~ ZIP Code 17ayr Side 1 L 1505610101 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number ~ ' W ' ~ ~ ~ r s Name: ~ Decedent ~ r RECAPITULATION 1. Real Estate (Schedule A) ......................................... .... 1. 2. ( ) ................................... Stocks and Bonds Schedule B ....2. ~~~r ~y • 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) p Separate Billing Requested ... .... 6. ""-`"`~""`~ • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C~ Separate Billing Requested.... .... 7. 8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. ~ ~ 9 9 ~ • / 3 9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. 3 / ~ / ~~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. ~ ~ (~ ~ Y •~~ 11. Total Deductions (total Lines 9 and 10) ............................. .... 11. ~ ~ ~ ~ ~ . ~ (~, 12. Net Value of Estate (Line 8 minus Line 11 } .......................... .... 12. 3 ~ ~ ` ~ l ~ ., 13. Charitable and Governmental BequestslSec 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. 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 A ~ 7 ~ ~ • Q ~ 16. f ~ ~ ~ • (~ 17. Amount of Line 14 taxable at sibling rate X .12 • 17. • 18. Amount of Line 14 taxable at collateral rate X .15 '' 18. • 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT f ~7~ '~~ O Side 2 1505610105 1505610105 J REV-1500 EX F'age 3 File Number Deee~ienf's Complete Address: DECEDENT'S NAME STREETADDRESS CITY i~l STA E ii ZIP ~ w d! ~~~ ~ i~~' 17 a ~/ l Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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. c1) /, '7~,~ , aid Total Credits (A + B) (2) (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~ ~ ~,~ ~ O~ 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; 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? .............................................................................................................. ^ 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 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 vvho has at least one parent in common with the decedent, whether by blood or adoption. L rii^I h ~~~_ /-...;~r_ EX+ of-0) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Robert Nailor 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. If more space is needed, use additional sheets of paper of the same size, RE;;-,503 EX (8-i2) i pennsylvania [7Ei'~RTMENT O~ R4VttiUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER o.~~ r~ 1 ~ ~ l© r Alt 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 ~ _ - ~:: ~~">=. -,.mss ~~ A~~~~~~a ~A~~4'~81'tlt~ ~a r~ •.+ ~~.,aso. f. ~-~- A Mme. t~ .. . R . . 'aY ..: a..: _ ,: b" ~'~ -c id1 :1+.. ~.. A d u .~~ a. .L.v`+~..~+ 1i. •x Jd R,~YGY -z ,.. -.__. - . .._ -, _. - - - ,_. a .... ._ -, r .., ... -, - -: -'s r' r. ^s _. .... .- f1 "~ °-~ ._ _ .. a - .. ,1 y+ fin '"T a-t r,' + ; 1' ~ ., ro r.: -* A "~ ~ -•. ~ °p »- <,- t~ r": ri •8 -b C . . .. ..._-.--~:-_--~+„~,-~,.... ,-,~.•.~--+-.~..n,--.-~-.,r,.,.-.~,e-. . r ::r....:Ar ~.-;.a. ~-.°~-:__.~--~-,-..-^" ._..d~..-... ;__...... ,:. -.e..,... ,t... ....~. .,.~-....... ...R~-~-..-~_-,-~.-s ...., _.~---•--...~--~~.-r- ~-cz-~,~. .._~ ~,_ `, ... , ,. , ...,.. ~ .. ,,., x,~: .. nom, ,x ~_ ti> s -~, - ..,,._ ~, ~~... .. .... _. ,~ i ~ >.. .. s pennsyLvania ~~~ DEPARTMENT OF REVEI`!UE INHERITANCE TRX RETURN RESIDENT DECE'~7ENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ------- ESTATE OF FILE NUMBER ., _ ___~_._....n..~_.._.......,_.._..~.... _. . Robert Nailor NA --~-~~~µ~ 1. Name of Corporation 4. Address _--__-~- _- City 2. Federal Employer ID Number 3. Type of Business __ Product/Service State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year STOCK TYPE TOTAL NUMBER OF pAR VALUE NUMBER OF SHARES VALUE OF THE VotingtNon-Voting SHARES OUTSTANDING OUVNED 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 8. 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 ^ No If yes, Cash Surrender Value $ Net proceeds payable Owner of the policy 8. Did the decedent sell or transfer 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 far each interest. s • ~- • r r 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 four preceding years. C. !f 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 relationships 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. State___ ZIP Gode {If more space is needed, insert additior:al sheets of the same size.} INHERITANCE TAX RETURN RESIL`ENT DECEDEP~T SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF _ FILE NUMBER Robert Nailor -Pd~--'""~"" 1. Name of Partnership Date Business Commenced Address -.-----. _- Business Reporting Year City State ZIP Code 2. Federal Employer 4D Number _ _ ___~~_ 3. Type of Business _--- - ---- ----- - - -- - - -- --- --- - - ------ - ----- ----- - ------- ProductlService 4. Decedent was a ^ Genera! ^ Limited partner. If decedent was a limited partner, provide initial investment '• PARTNER NAME PERCENT PERCENT OF INCOME ~ OF OWNERSHIP 6. Value of the decedent's interest $ BALANCE OF CAPITAL ACGOUNT 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 Vaiue $_.-_-------......---._--_-._......-.._....-_......__..--._._......_.....-....._..---.-._.-_-...-_......_..-.--.--.-.- Net proceeds payable ~ _- CJwner 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 transferredJsold 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. i 3. 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. Detaiied 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 four preceding years. C. {f the partnership owned real estate, submit a iist showing the complete address/es and estimated fair market valueis. if real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. - i~~ pennsytvania '~ DE=ARTMENT OF:EVENUE REV- s 507 EX+ (6-881 ~ SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTAT 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-1~o8 EX+ (08-12) i pennsylvania SCHEDULE E ~~ DEPARTMENT DF REVENUE CASH, BANK DEPOSITS 8c MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT CECEGENT ESTATE OF: FILE NUMBER: Robert Nailor 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 NUf~1BER DESCRIPTION OF DEATH 1. Saving Account No. 9644024 1,500.00 2 Certificate of Deposit (Robert Nailor No. 900004324350) 5,000.00 3 Certificate of Deposit (Robert Nailor, Connie Drawbaugh,and Tammy Henneman for 32,000 No.173850004) 10,666.66 4 Closing transaction of Robert Nailor's Checking Account No.125822 (09/20/2012) 15,070.43 5 Proceeds from Piblic Sale of Personal Property 10/27/2012 1,920.50 6 Proceeds from sale of 2007 Chev. 10/27/2012 10,000.00 TOTAL (Also enter on Line 5, Recapitulation) $ ~ 44,157.59 If more space is needed, use additions{ sheets of paper of the same size. REV-15og EX+ (oi-io) ~i, pennsylvania DEPARTMENT OFREYENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F )OINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Robert Nailor ..p~~.....-.----------______. 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 HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °/a OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL (Also enter on Line 6, Recapitulation) ~ $ If more space is needed, use additional sheets of paper of the same size. 0.00 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. i\. ~~ ... _.... .. _. ~\ i~ pennsylvania SCHEDULE G ~,~ DEPARTMENT pF REVENUE INTER-VIVOS TRANSFERS AND IrdHERITANCE TAx RETURN MISC. NON-PROBATE PROPERTY RESICENT CECEC;=NT ESTATE OF FILE NUMBER Robert Nailor NA This schedule must be completed and flied if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME CF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DP,TE OF TRA~JSFER. Ai.ACH A COPY OF THE DEED FCR REAL ESTATE. DATE OF DEATH VALUE OF ASSET ago OF DECD~S INTEREST EXCLUSION QF APPLICABLE' TAXABLE VALUE ~. /r,.....~ _... C./ .., ...w..._~_m_....,_.__... TOTAL ;Also enter on Line 7, Recapitulation} $ ~ 0.00 If more space is needed, use additional sheets of paper of the same size. .,:...:: ; ..: r~ ~~ i ~~ pennsylvania DEPARTMENT OF REL`ENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Robert Nailor Decedent's debts must be reported on Schedule I. 11 IfiU1C J~JGt,C IJ IICCUCU~ USC 6UU?LIUiiGI JIICCLJ Ui ~JG~JCI UI LIIC JGIfIC JiLC~ / Pennsylvania SCHEDULE I °raa~TMeNT of zEVErvut DEBTS OF DECEDENT, INHERITANCE TAX RETJRN RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Robert Nailor Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM P1UP9BER DESCRIPTION VALUE AT DATE DF DEATH °Z ~~//~~hrir.~~ /~~7~i~-~m~~ y ~Ys~ /~~v /~ ~ 1/r sd 3.~' ~~ ~E~~f~e•r ~Jc~ ~a d 4v,' ~~ ~ Y~ ~/~c~sc-a ~ ~jy/ S '~ a7 f~° ~' ~ ~~s%~~ ~ ssa~. ~N ~ aa,,~~ /~~SI~ i ~ ~ sty v ~ ~~ ~yt~ / /~,~ -1 N~'?~~/mot-~s /~~1 y 5i r iaH ~ f "~'7 „~ ~_ ~® ~~r~s~C~ ~~9~/S~e~~~.~ ~~'~~ / ~ .~`/ ~ Irr~ ~~ q~ ~~ nip ~~~/~ ~a ~~-,~ ~~.,~-,- ~u~ y ~~.~~- Yc~ c / C C~ l $ l / / / ` ~ ~ d ; ~-'s C~ r~ i s 7`Y,~ ~ .s -,~© r~ Fj/i h ~ ~~h~r~°! a ~C~ c.~ 1 Ot7. ~~; ~~ar% ~%t~ /y1 F'~ ,~y,~~ ~ ~t~Y /~/l~l L'~ ~3rk~ ~~ TOTAL ;Also enter on Line 10, Recapitulation) $ ~~~ ~' ~/.~DO If more space is needed, insert adCitiona sheets of the same size Rev-~s~~ ~x+ of-~o; pennsylvania SCHEDULE ] '~ Di:?ARTMENT OF REVENU= BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Robert Nailor If more space is needed, use additional sheets of paper of the same size. ' REV-1514 EX+ (4-09) `~~ i ~~ pennsylvania DE?AFTMEP.T 6E REVENUE Bureau of Individual Taxes PO Box z8o6oi Harrisburg PA 1']128-0601 SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CHECK BOX q ON REV-s5oo COVER SHEET) ESTATE OF FILE NUMBER Robert Nailor This schedule should 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. 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 below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME OF LIFE TENANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE -~-._.-.r..° ~" ^ 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 - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) . ...................................$ NAME OF LIFE ANNUITANT 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 - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructions.) ................................................ . 7. Value of annuity - If using 3.5, 6, or 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 that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. REV-1~4~ EX+ (01-10) `' Iii` p~ClC1S~/LVaClla INHERITANCE TAX bE?ARTMENTQERFVENI~'c SCHEQULE L INHERITANCETAxRETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST CORPUS I. ESTATE OF FILE NUMBER Robert Nailor This schedule is appropriate only for estates of decedents dying on or before Dec. Z2, 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 corpus (principal). II. REMAINDER PREPAYMENT: 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 Scheduie L-2 1. Unpaid Liabilities ..................... . .$ - _ _- __ 2. Unpaid Bequests .......................$ 3. Value of Non Includable Assets .............$ 4. Total from ScheduleL-2 ..............................................$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) .. . ..... . ....... . ......... .$ F. Remainder Factor ................................................... . G. Taxable Remainder Vaiue (Multiply Line E by Line F) ...... . . ....................$ (Also enter on Line 7, Recapitulation) [II. INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed ....... . . ........................................ . ..$ D. Remainder Factor ................................................... . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) ....................$ (Also enter on Line 7, Recapitulation) • REV-1645 EX+ (11-09) --L INHERITANCE TAX ~ Pennsylvania SCHEDULE L-1 DEPARTMENT CE REVENUE iNHERiTANCETAxRETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT ~ j -ASSETS- I. ESTA E OF FILE NUMBER II. ;ITEM NO. ~ DESCRIPTION VALUE A. Real Estate (Please describe.) `__. Total Value of Reaf Estate $ {Include on Section II, Line C-1 on Schedule L.) B. Stocks and Bonds (Please list.) Total Value of Stocks and Bonds $ (Include on Section II, Line C-2 on Schedule L.) C. Closely Held Stock/Partnership -Please list. (Attach Schedule C-1 and/or C-2.) Total Value of Closely HeIdJPartnership (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 {Piease list.} Total Value of Cash/Miscellaneous Personal Property $ ~ (Include on Section II, Line C-5 on Schedule L.) III. TOTAL (Also enter an Section II, Line C-6 on Schedule L.) $ If more space is needed, attach additional sheets of paper of the same size. ` REV-1646 EX+ (11-09} pennsylvania bE?ARTMEM1iT QE REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT I. ESTATE OF INHERITANCE TAX SCHEDULE L-2 REMAINDER PREPAYMENT ELECTION -CREDITS- FILE NUMBER - ~~D ~ c~Y'~f ~ ~ i ~ ~ ~~ IT. ;ITEM N0.1. DESCRIPTION A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets E Reported on Schedule L-1 {please list) -- - J--- 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. Calculation as folbws: AMOUNT { Total Non Includable Assets ~ ~ {include on Section II, Line D-3 on Schedule L) I III. ~ TOTAL (Also enter on Section Ii, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. . ' + REV-1647 EX+ (OZ-10) i ,, pennsylvania SCHEDULE M nE~a~rh~EN7 of ~EVENU~ FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN RESIDENT DECEDENT ~ (Check Box 4a on REV-1500) ESTATE OF FILE NUMBER Robert Nailor This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. n will n Trust rl Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1 _...._.. _ ._. . .._ 'r i 2. .~,,,-~ 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below 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. Summary of Compromise Offer: 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 shoUrn on Line 13 of REV-1500.} ........ $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ^ 6°io, ^ 3°10, ^ 0°!0 ................... . 5 (Also include as part of total shown on Line 15 of REV-1500.} 4. Value of Line 1 taxable at lineal rate Check one. ^ 6°l0, ^ 4.5% ............ . . . ........... ~ (Also include as part of total shown on Line 16 of REV-1500.} 5. Value of Line 1 taxable at sibling rate (12%} (Also include as part of total shoUrn on Line 17 of REV-1500.} ........ 6. Value of Line 1 taxable at collateral rate (i5%) (Also include as part of tots( shown on Line 18 of REV-1500.) ........ $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ....................... $ If more space is needed, use additional sheets of paper of the same size. ~.• REV-1549 EX+ X09-i2) i . i Pennsylvania SCHEDULE O ~, DEPARTMENT OF REVENUE ELECTION UNDER SEC. 9113(A) j INHERITANCE TAXES RETURN ~ (SPOUSAL TRUSTS) ~ RESIDENT DECEDENT ESTATE OF FILE NUMBER Robert Nailor PART A -DEFERRING STATEMENT For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is being elected under Section 9113{a), the personal representative responsible for filing the return and the trustee(s) of the trust in question hereby acknowledge the department's Statement of Policy set forth at 61 Pa. Code § 94.3 concerning any potential termination of the trust under 20 Pa.C.S. § 7710.1 that occurs after the return was filed. Specifically, the signatories recognize each individual's assumption of liability for inheritance tax consequences that result from any termination ofi the trust under 20 Pa.C.S. § 7710.1 that occurs after a return has been filed. Signature of Person Responsible for Filing Return Signature(s) of Trustee{s) PART B -ELECTION TO TAX AMOUNTS Complete this section only if making the election to tax available under Section 9113(a) of the Inheritance & Estate Tax Act. If the election applies to mare than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust {marital, residual A, B, by pass, unified credit, etc.). Enter the description and value of all interests for which the Section 9113(a) election is made. DESCRIPTION VALUE If rrjore space is needed, insert additional sheets of the same size.