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HomeMy WebLinkAbout01-08-13 (2)1505610105 REV-1500 °` t°z_11't~' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania ~^^^'.E~T°FA~~E Coup Code Year File Number Bureau of Individual Taxes ty PO Box ~sosos INHERITANCE TAX RETURN ; r~ Harrisburtrr, PA i~i28-06oi RESIDENT DECEDENT ' ~ I ~ ~ Q~ `1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY .......... _. Decedent's Last Name Suffix De enf first Name MI C~iQC mow' _ _ C~1GD~.v~. Gl/ _ _ (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 ~ 1. Original Retum O 2. Supplemental Retum O 3. Remainder Retum (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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION 8HOULD BE DIRECTED T0: Name Daytime Telephone Number c5~ C,4.2~ iti 7/''1- 73/-~~,3' X ~,, REG R;DF WILLS USE ONtIYI ;.~7 ~- C7 ~ First Line of Address ri .,YM3 ~ ~% +k~a r .. f; . 2/O~' ~/LOGE' .~G,Q~ r- ~; i ~.p i ~'- ~ r ~ o~ -. ~ Second Line of Address .~ ,,.~ ~,,~ --T~ -~ t --, : __ _ .:~ ~ . $ .. ~ ~ ~ ~~ ~' Ci City or Post Office State 21P Code r ~ .~ TE FILED ~ " _. tb ___ Correspondent's e-mail address: S /i7i ~C~.j ~ G Qy~ Under penalties of perjury, I declare that I have examined this return, indudi mpanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the pe ai representative is based on all information of which preparer has any knowledge. SIGNATU<`.. / RSON~ES ISLE F ILING RETURN DATE .Ey ~~ i ~ Zia G /~iaGE- ~a.¢~ ,~,~ ~icL , /~,~ i7ai~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J J REV-1500 EX (FI) 1505610205 Decedent's Name: ve/'~G'/~/i!G " `~ + `~'w~~ Decedent's Social Security Number .......... RecAPtruLATION 1. Real Estate (ScheduleA) ........................................ ..... 1. .......... _........... _ ... ~d ~ ~2 ..................... • d0 ~ 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. ~Q ~ ~S Z , ~ ~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .. ..... 6. 7. Inter-vvos Transfers i£ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... ..... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................ ..... 8. / v Z, ~ /~`Z 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. ~~ ~ ~! ~ O Q 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... ..... 10. ZGQ ~ Ot7 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. ~ :Z '~ j Qv 12. Net Value of Estate (Line S minus Line 11) ......................... ..... 12. ~'~ 6 8 ~ ~ ~ D Q 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. ~lj~Fj ~~ ~, d D TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 .......... i6. Amount of Line 14 talcable at li l t X 0 ~- ' ^ nea ra e . 16 / ~ ~~ C~ l;7 G 17. Amount of Line 14 taxable ~ _ - at sibling rate X .12 17. 1 S. _. Amount of Line 14 taxable at collateral rate X .15 18 I 19. TAX DUE ..................................................... .... 19., (~~ (j ~~ d 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610205 1505610205 O J 3460009201 REV-346 EX (03-OS) /'' //~~~~ Decedent's SocialzSecurity Number Decedent's Name: ~~L ~~/~~ ~/~/. ~,~,~-~-r<<//lam ~~~ 3~f ' 0 ,~ ~3 Co-Executor/Administrator Social Security Number Telephone Number Last Name Suffix First Name MI First Line of Address 2/~ 6 r.~ioG~ ~as~.z~ Second Line of Address City or Post Office State ZIP Code Co-Executor/Administrator Social Security Number Telephone Number Last Name Suffix First Name MI First Line of Address Second Line of Address City or Post Office State ZIP Code General Instructions: This form should be filed with the Register of Wills of the county of which the decedent was a resident at death. Please be aware the correspondent identified will receive all correspondence from the department. It is the responsibility of the personal representative to notify the department if the correspondent contact information changes. The department is authorized by law, 4Z U.S.C. §405 (c)(Z)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The department uses the Social Security number to identify the decedent and personal repre- sentatives of the estate. The commonwealth may also use the information in exchange-of-tax-information agreements with fed- eral and local taxing authorities. State law prohibits commonwealth personnel from disclosing confidential tax information except for official purposes. Side 2 L 3460009201 3460009201 J REV-1502 EX+ (01-10) "`~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INNERIfANCE 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 fartc_ .~ mine space is neeaeD, use aaamonal sheets of paper of the same size. REV-i5o8 EX+ (08-12) ;; pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHED~ILE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY tsinre vF: /y ~~~'G ~ / /~ FILE NUMBER: Include the proceeds of litigation and the date the proceeds were received by the estate. Atl property jointly owned with right of survivorship must be disclosed on schnrlu~n F ~~ ~~ iiwre sNace is neeaeo, use aaoitional sheets of paper of the same size. REV-1511 EX+ ;10-09) ~~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER zD~~. -C~S`9~ Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I. ~/l~,g~7viv uirr~y Ca~w~.s id ~ 31/'7 o 0 C«'~G C ' ~'oc~, o0 Unr~~ .¢~~~ c~ Cd~o~t~iz •9vT~y ~ ~- ~j 4 G' ~'fi ~ ~7'.'~-re y - ~ivo~ ~ ~ C~'~tiG~ct ' ~~ <.3sv, vo i ~~i,.aL zoo , o d ~i.~ y ~~.~ o ~.,a L ~iviv ~Z ,~ 2 s o a B. ADMINIST VE COSTS: 1. Personal Representative Commissions: a Name{s) of Personal Representative(s) Street Address _ City __ _ State ZIP Year(s) Commission Paid: 2. 3. 4. 5. 6. 7. Attorney Fees: 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 Probate Fees: Accountant Fees: Tax Return Preparer Fees: Q Sao , o0 0 TOTAL (Also enter on Line 9, Recapitulation) ~ $ ~ ~~/, d U SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ZIP If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ ,12-12} ~'i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /7 ~ /~ ~ SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER ~~iz ' OOS9y Report debts incurred by the decede~ prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. ~~ ~~ ~Cilns ~~i~ OGtlp/L u.,pG Li~~jL Z U ~ /~ G3 3 ~~'!nS ~ cry/w ~'"~~~/fG•~ v - G ~ ~, ~/ ~~ y G:~~~~U -~~w ~' ., ~ ~' D o .S ~/'s,4 / ~'~ 6~ C'o~- ~~ ~ y~ ~8 7 T ~ ~r,~,r~/~ -- lr~~ C,~~ ~ /-iz> SC, ~ TOTAL (Also enter on Line 10, Recapitulation) I $ Z, 6 0.00 If more space is needed, insert additional sheets of the same size. REV-1513 EXt (Oi-10) ~~ pennsylvania ` SCHEDULE ~ ' DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF• ~~~r~~~ ~ c FILE NUMBER: ~ z ~~Z -Gassy NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RE o NotSList Trustee(s~NT AMOOF ESTATE ARE I TAXABLE DISTRIBUTIONS I l d [ nc u e outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] ' 1. ~/YG/! ~ C~/'iZ e5'~Uic/ SfJ /D /G3/ ~lG'c~~i~.~ ~i ~~ ~ isiy,3 . ~~ ~,~ ~~,~ L ~ ~ , ~~~ ~o~ saw 2/G~ 6~ ,~ivGE ~a,~i~ ~irrP ~/~L ~q /70 // ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 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 ~ O If more space is needed, use additional sheets of paper of the same size. REV-346 EX (03-09) 3 4 6 0 0 0 9101 ESTATE INFORMATION SHEET ~ pennsylvania Foiz rz~~a~~retars c~F~ace use or~~w OEPARTMENi OF REVENUE County Code Year File Number DECEDENT INFORMATION: Eller data as it will appear on all documen submitted the De artment. Decedent's Social Security Number Date of Death Date of Birth icy-3~-oGs~ os-~i -ice C~7- ~3/- ~ ~, Last Name Suffix First Name MI TYPE FILING: Fiil in oval to indicate the nature of the return to be filed with the department. ~! Probate Return CD Joint Assets Only ~ Non-probate Assets Only C Litigation Purposes (no other assets} D: Fill in oval to indicate the nature of the proceedings at the Register of Wills Office. (Attach additional sheets if explanation is necessary.) ~ Testamentary O Administration C~ No Letters C~ Other (Please Explain.) ATTORNEY/CORRESPONDENT INFORMATION: Enter all information for the attorney or individual to receive tax information and correspondence. Last Name/~,,~ Suffix First Name C/`7/C.~ /~ MI V~ Supreme Court LD. # Telephone Number /T/ ~_ ~~/~~~ A orney/ Corre`spond~en~t's e~-mail address: _ / G~s~/~U~-~ ct G_%f/Qip ~ First Line of Address z/aG ~%~~- ~~,~~ Second Line of Address City or Post Office State ZIP Code PERSONAL REPRESENTATIVE INFORMATION: Enter all information for the personal represerrtative(s) of the estate authorized by the Register of Wills. Executor/Administrator Social Security Number Telephone Number /~~ 3f,~- fJG.C3 7i~ 73~ -~~G3 Last Name Suffix First Name MI C.~~2~iw ~-- ~, First Line of Address / ' _ __ 2/06 ~ C'i,~C~~' .~o,~.~ ~. _ _ _.. Cf~FICIAI. USE ONLY Second Line of Address ~ 7RANSACTI43N C(kUN7` i City or Post Office State ZIP Code Complete general estate information questions and indicate additional personal representatives on reverse side. PLEASE USE ORIGINAL FORM ONLY Side 1 L 3460009101 3460009101 J REV-1500 EX (FI) Page 3 Flle Number ~~~ ~.Q/J ~~[~ Decedent's Complete Address: ((JJ 7 c~~CC~4.d~~v~ GU. G~~~ iiy STREETADDRESS - 3/ c~a~r~ ~~'cati.~ s'rs~~_~ CITY STATE ~~ ZIP ~~~ ~ rs;E~u~6 /7'0/,3 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) ~ / /~ + 0 2. Credits/Payments (D A. Prior Payments B. Discount 3. Interest Total Credits (A + B) (2) t3 , ~j () 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) ©, U ~ Fill In oval on Page 2, Line 20 to request a refund. (4) ©~ ~ a 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~ ~ ~Q ~ ~ d Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIAT E 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 ......................................................................................................................... d. receive the promise for life of either payments benefit ? ..... ^ , s 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 benefaary 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)j. 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)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted in (IZ P.S. §9116(a)(1)j. • 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)j. 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.