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Home My WebLink About12-31-12J 1505610105 REV-1500 EX (02-11) (FI) OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes oEPARrME~roFaE~E~~E INHERITANCE TAX RETURN PO BOX 28o6oi County Code Year ~ 1 File Number ~ i n RESIDENT DECEDENT H PA b 8 6 ~ i ~ / /~ arris urg, i~i2 oi -o ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY _. ._ , - -, ; _, A. ~- ~ r c Decedent's Last Name Suffix Decedent's First Name MI r` n F P' (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 FILE D 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 Retum 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numbex , ~ ~.~~ First Line of Address Second Line of Address City or Post Office 1 Correspondent's a-mail address: State ZIP Code _, RE ER~OF WILL~$E ON,~f C ~ ;'~ :,:::~ ,,.~.. ~ -erg ., . ~ . _,. _._.., i J ,. .., "~ C.J ' a °. t~ d ~~..~ ~ ~~d~ C:.`~ DATE FIL Under penalties of perjury, I declare that I have examined this return, incl ding 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 ersonal representative is based on all information of which preparer has any knowledge. ~ S NATURE PERSON SP NSIBLE FOR FILIN ET R DATE ADDRESS l .. ~~ ~ f' ~ ~ ~ SIGNATURE OF PREPAR R OTHER THAN REPRESENTATIVE DATE ADDRESS 1505610105 ~ - ~ ~ r~` PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 `~ r ,~ ; ~~ ; J REV-1500 EX (FI) Decedent's Name: ~~ }'~ ~ ~ ~,~'~,'._ ~ ~, ; ~ • ~, ~• ,- 1505610205 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. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. "" ~ ~~ -- r. __ ,.._ r', ____ r_• ~;. ~_ _. ~.. ~ -, _~ _. 9. Funeral Expenses and Administrative Costs (Schedule H) .......... ......... 9. 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ...... ......... 10. 11. Total Deductions (total Lines 9 and 10) ........................ ......... 11. 12. Net Value of Estate (Line 8 minus Line 11) ..................... ......... 12. 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. ~., ~ ~ ~ ~~ ~ _ -~ 1 l.~ ~ t" ~~ r. ~~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 ~~ 16. - r'~ -- 17. Amount of Line 14 taxable at sibling rate X .12 17. -- (r --~ 18. Amount of Line 14 taxable at collateral rate X .15 18. '-'" ~ ` 19. TAX DUE .................................................. ~A , .......19. - r---. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O i ``` ~ ~ ~ i ~'~ t~ ~ `: Decedent's Social Security Number • ~: ~',~ $IC~@ 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME __ _ l ,^ STREET ADDRESS ~~l , :~ - l ~a=, - ~ ~ __ •~ -- - __ _ _ - CITY ~ . _ _ ,STATE ~v~ l ZIP ~ - ~ _~ 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. 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 .......................................................................................... ^ ~] b. retain the right to designate who shall use the property transferred or its income ............................................ ^ ~] c. retain a reversionary interest .............................................................................................................................. ^ tl. 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 tlesignation? ........................................................................................................................ ^ ^ 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(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-1508 EX+ (o8-iz) i pennsylvania SCHED~ILE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ~~Y\~ C)~L. ~ ~'~ 1 t'~ f ~ Y 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. If more space is needed, use additional sheets of paper of the same size.