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Home My WebLink About03-21-13 1505610101 REV-1500 EX(in-10) OFFICIAL USE ONLY 1�$d. PA Department of Revenue Pennsylvania Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN p , 1 Harrisburg PA 17128-0601 RESIDENT DECEDENT ! ENTER DECEDENT INFORMATION BELOW " Social Suffix Decedent's First Name MI (if Applicable)Enter Surviving Spouse's Information Below Spouses Last Name Suffix Spouse's First Name MI 17 u...0 ,Ab.,m, k. .?aura ,",,,. mw .: `• w-n;-.u<,x n- Spouse s Social Security Number +� < >r° THIS RETURN MUST BE FILED IN DUPLICATE WITH THE x . .0 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW i® 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 Return Required death after 12-12-62) 1111111 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. Etection to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Soh.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number T. r,IRqJIVfR O ILLS; ONLY �u D rn fj r„I First line of address Pa r�} :�x '.,,.' :1 Second line of address y..rl If City or Post Office HI State ZIP Code DiQ FILED P obi m u .a Correspondent's e-mail address: Under penalties of perjury,I declare that 1 have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is t ,correct and complete Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. S TORE F PE RSp S LE FOR FILING RET RN D /1.2 E �/ 3 r 1Z,131 2t1 12 S! TUBE OF PRE PARER O RR T/� RESENgTATIVE J) ,p /�/} 1 / ^y�-, DATE ADDRESS 7 �h( '/ �CTy-) L 1 �Ir!/ sli //I"� / �o/1 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Na+ne: RECAPITULATION 1. Real Estate(Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. 3. x 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . 4 '-^ V 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 8.Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.. . .. . . . 7. 8. Total Gross Assets(total Lines 1 through 7).. . . .. . .. . . . .. . . . . . . . .. 8 T :v.. gj 1 13'. it 9. Funeral Expenses and Administrative Costs(Schedule H).. . . _. . . . . . . . .. . . . 9. .. 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . .. .. . . ... ,. 10, •(.�'x 11. Total Deductions(total Lines 9 and 10)..... ....... ... _. ... . .. ... ... _. 11. f a 12. Net Value of Estate(Line 8 minus Line 11) .......... ..... .... . . ... ... ... 12. ;. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made(Schedule J) ... . ... . . . ... .. ... . ..... 13. 14. Not Value Subject to Tax(Line 12 minus Line 13) . ...... .... 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 t xabie '' '�`^`q °"';k �j at lineal rate X.0`�' O 16 f 1 -1 17. Amount of Line 14 taxable r at sibling rate X.12 IT 18. Amount of Line 14 taxable ¢ at collateral rate X.15 - 18 ; 19. TAX DUE ..... .. .... ....... .. ..... ...., ... 19 1r.� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505610105 1505610105 IRL age3 File Number Decedent's Complete Address: DECEDENT'S NAME STVEET Amuss CITY STATE ZIP Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) 2 Credits/Payments A.Prior Payments __0 B.Discount v Total Credits(A+8) (2) 3. Interest 0 4. If Line 2 is greater than Line I +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line I +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (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 N 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.........-..............._........-.................................................. .................. ❑ [�q 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?..................................... .......... ....... ... ........ 1 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? .....___................................____......... ...... ....._......------ ❑ �0 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)(11 A)(i)j. 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) (4)]. 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)).A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. RPJa�4E%�(t9n SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MSC. INHRESERITANCE TAX EDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigatlon and the date the proceeds were received by the estate.Ail property jcintlyownad with the right of survivorship must be disclosed on Schedule . ITEM NUMBER DESCRIPTION VALUE AT GATE OF DEATH ,. /)SECV 8C?r7x �7c&cxlt fiomheC $ a3 , AF-F 3 i TOTAL(Also enter on line 5,Recapitulation) $ a (If more space is needed,insert additional sheets of the same size) REV-1512 EX+ (12-08) �pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE ED RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH ,00 13ad-rd, Q-7 C?r5CS 6CP 1,4l- ZT 2oiZ 2 ra' 1'`am mCc1i'C?g1 foe Ncif5jn5 F-L yiew 1XI-7r7er 13 3 / . I I TOTAL(Also enter on Line 10, Recapitulation) ¢ g3O7 ZS If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERrrANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.2116(a)(1.2).) I. ,21chad CI - 12-� tl Z E 00 C 0176cto(� �/i/1e Arle- 3 fn&-19 rno rry w slnebl-&-7 fCjty 1';)C9d5 t-ter s � Z30- r2j �/-vrn 9"v v� t ✓► ra r t Z 59, 0-3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II 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. i TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,insert additional sheets of the same size.