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Home My WebLink About04-08-13 1 1505610101 �••1 REV-1500 EX(ci-io) OFFICIAL USE ONLY Department of Revenue penrSryHvarlia Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN ® L= Harrisburg,PA 17128-0601 RESIDENT DECEDENT i (. Date Of Death MMDDYYYY Date of Birth MMDDYYYY FIA&L023 LIJ&PAIA Decedent's Last Name Suffix Drrecedent's First Name ��nn MI (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Mi L7 1 77 [] Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE [7141713F1= REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 4M 1. Original Return O 2.Supplemental Return (M 3, Remainder Return(date of death prior to 12.13-82) O 4. Limited Estate p 4a.Future Interest Compromise(date of (M 5. Federal Estate Tax Return Required death after 12.12-82) p 6. Decedent Died Testate p 7.Decedent Maintained a Living Trust O'� 8, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) C=) 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O N. Election to tax under Sec.9113(A) between 12-31-91 and 1-1.95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number a JILLU 1-A1 1-U-e AAi ,1A REGISTER OF WILLS USE ONLY First line of address p '- r z c-> xf in a Second Tine of address to CO M CY x City or Post Office State ZIP Code C'TE -n m " rift fv cno rn 'n Correspondent's e-mail address: Under penalties of perjury,I declare that I have examined this return,including accompanying scheftles,and statements,and to the best of my knowledge and belief, it is true,qWrect and complete.Dedaration of preparer other than the personal representative is based on all information of which preparar has any knowledge. SIGN E OF PERSGNPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE O PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security RECAPITULATION 1. Real Estate(Schedule A). ... .... .. ... .. . ......... 2. Stocks and Bonds(Schedule B) . . . . . . .. . . . . . . . . . . . . . . . . 2. ' 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... 3 Y 4. Mortgages and Notes Receivable(Schedule D). . . . . . . , . . . 4 5. Cash,Bank Deposits and Miscellaneous Personal po Property(Schedule E)..... 5. :. z 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . . .. 6, 3 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested... ... 7 8. Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . . . . . . . . .. . . .. 8. 9. Funeral Expenses and Administrative Costs(Schedule H). . ... ... .. . . ... .. 9 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ......... . . ... 10, 11. Total Deductions(total Lines 9 and 10). . . . . . . . ... . . . . .. . . . .. 12. Net Value of Estate(Line 8 minus Line 11) ... . .. . .. . .. 12 $ 5+ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . .. . . . . .. . . . . . . . . . 11 , i 14. Net Value Subject to Tax(Line 12 minus Line 13) .. ... .. . ._..... .. .... 14. 'TAX CALCULATION-SEE-INSTRUCTIONS FOR APPLICABLE RATES 45. ''�tnount of Line 14 taxable at the spousal tax rate.,or .� transfers under Sec.9116 „....- "< 0(12)X_0_ T I 1L kbount of Line 14 taxable 7r s. 1 fhy r aj'lineal rate X.0_ 16. z .a r 4 1 Amount of line 14 taxable a €bong rate X .12 r 17, lgAmount of Line 14 taxable at collateral rate X.15 ” " ,y y 18" 'A r, 19. TAX DUE .. . . . . .... . .. .. . . . . . . . . . .. . .. . .. . .. . . . . .. . . . . . . . . . . ... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610105 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STREJETADDRESS CITY ZIP //,4 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 1 Interest (3) 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 No a. retain the use or income of the property transferred;....__......__......._.......-.................................................... El E�_ b. retain the right to designate who shall use the property transferred or its income;..._.............__......._........ . ❑ [a c, retain a reversionary interest;or................................................................................................................. ❑ a d. receive the promise for life of either payments,benefits or care?.............___..............__......... ... ❑ B 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?..........................................._.................................-.................".. ❑ C-7 1 Did decedent own an"in trust fiv*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&§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 decedents siblings is 12 percent 172 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. REV;1503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER // id AC All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER _ DESCRIPTION OF DEATH TOTAL(Also enter on line 2,Recapitulation) $ (if more space is needed,insert additional sheets of the same size) REV,1513 EX+ (01-WO 10 pennsylvania SCHEDULE DEPARTMENT OF REVENUE INHERITANCE 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 DISTRIBUT1 NS(Include outright spousal distributions and transfers under Sec.9116(a)(1.2).) 1. ��,,� / r�4s/c T�� n Sao JT .V a Af 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 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1560 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size.