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Home My WebLink About07-15-13 __ _ , � _ -�.�ww I '" J 15�5611101 II REV-1500 Ex�°�"> 1�f PA Department of Revenue Pennsylvania oFFICIA�uSE oN�r I Bureau of Individuat Taxes "�°'"`" County Code Year File Number PO sox zso6oi INHERITANCE TAX RETURN Harrisburg,PA 1'71z8-o6o1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � � � � 3 � saa ► � � � 3 � � � � � �� Decedent's Last Name Su�x DecedenYs First Name MI � �. �, , � � � � � GA : f l D � 0. � . , �. Rot .x;.�.rz�� ;n�... �} (If Applieable)Enter Survivi Spouse's Information Below Spouse's Last Name Suffx Spouse's First Name MI . . . ; . " ��: " . � � g�. . .. . .. .. : � ,,,. ',....... :. .... ...� . . . .;. .„�;'. Spou;e's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ' " ' REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW e� 1. Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death � , .� , , Priorto 12-13-82) p 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Taz Retum Required death aker 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 Tmst.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(Date of Death O 11.�iection to Taxuader Se�.y�4�3(A) Between 12-31-91 and 1-1-95) �ltt�Schedu�e O) � C CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE ANU CONFIDENTIAL TAX INFOR I�S�ULD B�E-'DIREPJEWD: Name Deytir�T phone humber�^.r � ma r � i �A � G�� Ca � I oway � A �� :� �� -� c, - � ,W.., .,s� __+ � " Qt£CQBTEfp OF LS U&�QJ}j�Y O � r.� �._: r'� � f�J �,._ ff7 First Line of Address � W w•� G � ..�;�..,x, A . � ', ?s ;U -rt `f� ��, N� �'�1`�`� � ,�� tR �� Second�l.ine�of Address ' �.. .. . . ,�.._ ..�„... ... � � CI(y of POSt OffiCe S[ate ZIP Code DATE FILED LS '� 1 ; n ►� � b $ $ 3 u Correspondent's e•mall address: Untler penalties o�perjury,I declare that 1 have examined this return,including accompanying schedules and statements,and to tha best of my knowledge and belief, it is We,cortecl and comple[e.Declaretion o/preparer other ihan the personal representative is based on all information o�which preparer has any knowletlge. UF�.OE PER N ��IBLE�R. FILINjRETURN DATE/� p �`/ y j� %4fU.f L U 7 AD R SS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAI FORM ONLY Side 1 L 1505611101 1505611101 � �� - _ ^ � � � . r � 0 r ru r � � F �- . .—_ ___ _ __ O � O O � O /� �' � � � � . . 1 � o �� .�.� 1 �.�. �', � � � = ` � _ �trY J� / W / � � C> �.; �G7 - � f � .s� � c__ c:�� p �° ai '�' � -, .._,. ,r .� ........_ f't _.� C'� .._ �`: .. nJ �� I- F.� ....: .�:_' ' � �„' ..i C7 . <7 . �.J •""� V� '' � - O ,_] LJ C� � �. ' ...i � C. . � � •,_.� .,� � �,. w C� � . :� f�t Y1-I � -Q � C.J G� C�� _ • ;V 'Tl ' J J i � � �I� � o �O �M •J W 9 . O _ _ N � C o �JmDN �� ~��O�C�'� . �� w � �N 0 ,��_�.��,- _- M.. .... . �.. _��„- -_�, j1'l�.'.1larcia(;.Cullowa�� ;: 4.,,�<<¢4'J.i':1.�. Y.f,.� i°:°y:, . „,,..-.-»..��..,..r:: „�..,. ��V'Hcnt�� PI � . ,,`"'_"'�"„�� Iscli��.\.IO8:Y;u � �"i .�.A�.'�1i3 3='h� 'a�` � '."�„�„�+'" ,. ,..,.—..,,:>, i ; -•�,,..r:.�-.: 1�JUUUIIDl.' ��11� D QFfICF 0�', , li1 �.1�.�.QQ,� ��; G 1" . , S � �Iu.�JU. '! i3 JUL 15 Pfl i 23 Pa. l�ol3-33g? C,:c�;� U;� ORPNANS' COUR�1" CUMBERLAND CO., P�9 �II i��{UI�f��l11�1�I'ljrltu�v��ylhii�fll�'�1�1'l��'�}��'��1��11'111�1�11'i�' i Z a!3'333'92 _ ._..__ . _.. . . � . � J 1505611201 � � REV-1500 EX DecedenPS Social Security Number , Decedent's Name: .�a �a- RECAPITULATION 1. Real Estate(Schedule A): . ... .. . . ... � *. . � . '. . , �... � =:..� F .....� , �.. . .�.., . . . . . . . . ��. . . .�. . . . . . . . . ..� 1. � , . + . �2. Stocks and Bonds(Schedule B) . .. . . . . . . .. . . . . . . . . . .. . .. ... . . . . . . . . . . . 2. � �� ' . . , : � � s, l �� ,*� .�,�, �,� ; 3. Closely Held Corporation, Partnership or Sole-Proprietorship,(Schedule C) . . . . 3 ' � .R.�:`v s�... r.,�"":+5y",*.�k,,u „ � 4. Mortgages and Notes Receivable(Schedule D) . . .. . . . . . . . . . . . . .. . . . . . 4. s % �i � �s�sr. . . � . . . 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . . . 5. ��.�� ,+ . 6. Jointly Owned Property(Schedule F) � Separate Billing Requested . . . . .. 6. � � ��' � ui� ,J . � �� 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property �� (Schedule G) O Separate Billing Requested.. . . . .. . 7. . 8. 7otal Gross Assets(total Lines 1 throu9h 7). . . . . . . . . . . . . . . . . .. . . . . . . . . . . 8. [ �. G� � a � 'O �� 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 � � � � �y�; . `v.` .. .. � . .., .. 12. Net Value of Estate(Line 8 minus Line 11) . . _ . . . . . . . . . . . . . . . . _ . . . . 12 � � � . � } ` 13. Charitable and Governmental Bequests/Sec 9113 Trusis 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)�L2)X .0- , . .- ' 75 , �E � _ � � 16. Amount of Line 14 taxable . � � 'k' �� ` ily� "�� "��4 . � at lineal rate X.0_ K 16 � �� * 17. Amount of Line 14 taxable �"�''� ° ��"`�� . � � . � �: � a at sibling rate X.12 r �� : 17 .'� . 18. Amount of Llne 10.taxable � � ' �� f �`��`�� „`��" � • "'� �� s`. at collateral rete X.15 �� 4F . 18. ' � � � • '� ' � 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . ... . . 19. . �� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT , . Q Side 2 � 15�5611201 1505611201 � ... y n [� I REV-1500 EX Page 3 File Number:.1 I I� ,. I�X � W V Decedent's Complete Address: DEC E T'S NAME _�f 3� ��lou�� -- — _ __ __ --- — - - --- STR T R SS - ��_�� n�5�_��4(� ._ _ ___ _ _-- - ___ _-_ _- _ _--- __- - --- _-- STATE ^ T ZIP ^ aTV � � S�� v�. i Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (�) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 3. Interest (3) 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. (4) 5. If Line 1 +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.......................................................................................... ❑ � 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,benefts or care?...................................................................... ❑ � 2. If death ocwrred after Dec. 12, 1982,did decedent transfer property within one year of death rth without receiving adequate consideration?.............................................................................................................. ❑ L7I 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 benefciary designation? ........................................................................................................................ ❑ � IP THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETUR . '"�±�`� � �, ��;.��_ . , .. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of tiansfers to or for the use of the surviving spo se 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 per nt [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from lax,and the statutory requiremenis for disclosure of assets nd filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after Jury 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)(12)]. • The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal benefciaries 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 decedenfs siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defi ed, under Section 9102, as an individual who has at least one parent in common with the decedent,whether by blood or adoption. RCk+-1502�Fr{61-1b} � "�i�'pennsylvania SCHE�WLE A j� �EPAftTMENT t}f FEVENUE cNr+eanaNCe Tax�eTURN REAI. ESTATE RESIDENT DECEpENT ESTATE OF: FIEE NUMBER: All real property owned eolely or as a tenant in aommon must be reported at fair market value.Falr market value is defned as the price at which property would be exchanged between a willing buyer and a willing selle5 neither being compelled to 6uy or sell, both having reasonable knowledge of the relevant facts. . Reai property tirat is jointiywwned with r�ght af wnrivorship must be dicdased o�ScM�ute F. Attach a copy of the settiement sheet if the property has been sold. [TEM Indude a copy of the deed showing decedent's interest if owned as tenant in comman, VALUE AT DATE NUMBER pF DEATH ( DESCRIFTIQN 1. � k � TOTAL{Also enter on Line 1, Recapitulation.) $ If more space is needed,use additlonai sheets af paper o#khe same size. ___ __. _ ,___ _ _ , REV-1503 EX+(6-98) II� scNEOU�,� s �' COMMONWEALTH OF PENNSYLVANIA STV\.KS 0[ BONDS �� INHERITANCE TAX RETURN �'�.. RESIDENT DECEDENT I ESTATE OF FILE NUMBER All property�ointly-owned wlth right of aurvivorship muet be dleclosad on Sehadule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) _ __ _ REV-�SOa6X+n-9» SCNEpULE C Ii CLOSELY-HELD CORPORATION, ! COMMONWEALTH OF PENNSYIVANIA PARTNERSHIP OR I INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP '� ESTATE OF FILE NUMBER Schedule C-1 or G2(including all supporting information)must be attached for each closely�held corporetion/pannership interest of the decedem,other than a sole-proprietorship.See instmctions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. TOTAL(Also enter on line 3, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) R2V4505 EX+(6-SB) . I; scNEOV�� c.a , GOMMONWEAI.TH OF PENNSYLVANIA Cl4SE�Y NELD Ct�RP'ORATE i INHERITANCE TAX RETURN STOCK INFORMATION REFC}RT ( RES@ENTDECEDENT ESTATE OF FlI.E NUM6ER 1. Name of Corporation ._ State on Incorporation Address�,_._,___. Date of Incorporetion Ciry__._,_.__^___State_�p Code Total Number of Shareholders 2. Federal Empiayer i.D.Number:._,�..,__._.._. 8usiness Reporting Year 3. Type of Business_.�_.� ProducUService 4� �- � , , . „ ' , . $1'�K ��' � �'; .P��' � 2�,�^ ? .' Common � Preferred � Pravide all rights and restrictions pretaining to eaoh class ot stock. 5. Was the decedenT employed by the Carporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑No if yes, Position__,._ Annual Salary $ Time Oevoted to Business 6. Was the Corparation indebted to the deceder�Y? . .. . . .... . . . . . ..... . . . . ..... . . . . ... ❑Yes ❑ No � If yes, provide amount of indebtedness$ 7. Was there Ufe inaurance payable to the wrporation upon the death of the decedent? . . . .. ❑Yes ❑ Na Iif yes, Cash Surrender Value$_, �._ Net proceeds payable$ , Ownat of the policy i &. Did the decedent sell or transfer an stock in this company within otie year prior to deaih or within two years � if the date of death wae prior to 12-31-62? ❑Yes ❑No I(yes, ❑Transfer ❑Saie Number of Shares Transferee or Purchaser Consideratian$ _Date Attach a separate sheeT for additional transfers and/or seles. 9. Was there a written sharehoider's agreement in eTFect ai the time o(the decedeM's death? .. . .O Yes ❑No If yes, provide a copy of the agreement. 1o. Was the decedenYs stock sold? .. .................... ............................... ❑Yes ❑ No tf yes,provide a copy af the agreement of sale,etc. 11. Was the oorporation dissoived or liquidated atter ttie decedem's death? ..... ............... CI Yes ❑ No If yes,provide a breakdown of distdbutions received hy the estate, including dates and amounts received. 12.Did the corporation have an interest in qther corporations or partnershipe? . . . . . . . . . . . . ❑Yes ❑ No I if yes,report the necessary in#ormatian o�t a separate sheet, Including a Schedule G-1 ar G2 for each interest. s •� r A. Detaiied catculations used i�tlie vaivatian of the decedenYs stock. B. Complete copies oi fina�cial staieme�ts ar Federai Corporate ir�ome T�retums{Form 1124)for the year of dsath and d preceding years. C. It the corporetion owned real estate,submit a list showing the complete address/es and estimated fair market valuels.If real estate appraisals have been secured,attach copies. D. List o#pri�cipai stockhoiders at the date of death,number r�f shares treid and their relationship to the dacedent. E. List of afficers,their salaries,bonuses and any other benefits received from the corporation. F. Siatement of dividends paid each year.List those declared and unpaid. G. Any other information relating to the valuation af the decedenPS stock. p(more space is needed,insen additionai sheats of the same size) I � � • AEV�1506 EX+(9-f10) scNEdu�E c-s COMMONWEAITti Of PENNSYlVAN7A PAR7NERSHIP I INHEpITANCE TAX RETURN INFORMATION REPORT AESIpENTDECEpENT EStATE 4P Ft�E NUMBER 7. Name of Partnership Dats Business Commenced Address Busirress Reporting Year i City� State Zip Code 2. Federal Emplayer I.D.Number 3. Type of 6usiness_ ProducdService 4. Decedent was a ❑Generat ❑�imited partnec lf decedent was a limited partrfer,provide�itiai investment$ 5. fZ! A. - B. - C. - D. 6. Valne of the dscedenYS interest$ �. Was the Partneiship indebted to the decedsnt? . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . ❑Yes ❑ No !f yes,provide amount of indebiedrress$ 8. Was thera lite insurance payable to the partnership uppn ihe death ot the decedent? . .. . . ❑Yes ❑No If yes, Cash Surrender Value$ _ Net proceeds payable$_ Qwner of the policy--- i — 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was priorto 12•31•82? ❑Yss ❑No if yes, ❑Transfer ❑Saie Percentage transfertedjsaid Transferee or Purchase� __.,,, Gonsideretion$__ Date Attach a separate sheet for additional transfers and/or sales. 10.Was there a written partnership agreement in affect at the 6me of the decedenfs death? . .. ,.. ❑Yes ❑ No Ii yes, prpvide a copy of the agraement. 11. Wasths decedenYs partnershipintarastsWd7 ....................................... Q Yes Q No If yes,pmvicle a cropy of the agreemen#of sa�.etc. 12. Was the partnership dissolved or liquidated after the decedenYs deatlr? . .. . .. . . . . . .. . .. . . . ❑Yes ❑ No If yes,provide a breakdown of distri6utions received by the estate,iricluding dates and amounts received. 13.Was ttre decedent related to any of the parfier&? .... .. ........... ..... . . .......... .. Ct Yes ❑No If yes,explain i f 4.Dkf the partnership have an intsrest in othsr corporations or partnerships? .............. ❑Yes ❑No T if yes, report the necessary iniorrnation on a separate sheet,inGUding a Schetlule C-1 ar G2 far each interest. • � A. Oetai�d cai�ulations us�in The vaNaation of the decedenPS partrrership irrterest. B. Complete copies of financial statements or Federal Partne�ship Income Tax retums(Fortn 1Q65)for ths year of death and 4 preceding yeara. G. if ihe partnership owned reai estate,submft a lisi showing the c�mpiefe addrass1es arrd estimat�fait market valu�s.If r�!estate appraisal&have bsen secured�attach t�pies. D. Any other intormation relating to the valuation af the decedenPs partnership interest. .. . . _ _ . . . . . _ __ . . _ .i . . Fi�V-1507 EX+(1-97) scNEOU�E � COMMONWEALTHOFPENNSVLVANIA MORTGAGES Ft NOTES I INHERITANCE 7AX RETURN RECEIVABLE I RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointlyowned with right of survivorahlp must be diaclosed on Sehedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 4, Recapitulation) $ (It more space is needed,insert additional sheets of the same size) . . _ RE�-t5o8 EX+(ii-io) II �pennsylvania w SCNEpYLE E I �„�� DEPAPTMENT Of FEVENUE C/WH� BANK DEPOSITS & MISC. iNHenrrnNCernxaErunN PERSONAL PROPERTY ' RESIDENT DECEDENT ESTATE OF: FILE NUMBER: I ►i - ID$ Include the proceeds of litigation and the date the proceeds were received by the estate. All property joinNy owned with right of survivorship muet be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �� [.i ncoi� irnrn �ga�, TOTAL(Also enter on Line 5, Recapitulation) ; 6�� If more space is needed, use additional sheets of paper of the same size. R�V-i5og E�+{gi-io) � pennsylvania SCN�pYLE F R�`l �EPAPTMENTOF%EVENUE ,N„ERSTa�r�ETAxRETORr� 742NTLY—OWNEDPROFERTY REStDEitlT DECEpENT ESTATE OF: FILE NUMBER: '�' ( •'Q _ If an asset became joindy owned within one year of the decedeM's date of daath,it must be repoM�ad on Schedule G. SURVIVINGJOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIPTO DECE6ENT A g�� an r�,�t�. �`� t s� o �r�� d � B. C. � I 7pIMTLY QWNED PR4PERTY: �7iER DAie DESCRIPT[pN OF GRppERTY %oF DAiE OF DEnTH ITEM FOR JOINT MADE INCLUPE NAME OF flNANQAL INSfITUT10N AN�BANK ACCOUNT NUM9ER OR SIMILAR DATE OF DEATH OKEDENT'S VAWE pF NUMBER TENANT ]OINT I�ENRFYING NUMBER.ATfqCH OEED FOR]OINTLY HELO REAL E5TATE. VALUE pF ASSET IN(ERES( OECfDENT5INTE0.E5T i. A. P,S�' �`3��-in�S� �6p,� ��5�•�1� � � 1�i��od�. � � � i � c � TOTAL(Alsa enter on Line 6, Recapitulation) � � ��a If more Space is needed,use additb�al sheets of paper of the same size. I , RE✓-1510 EWr (08-09) I ,�i 'pennsylvania SCHEDULE G Ly oePAA.neNroFAeveNUe INTER—VIVOS TRANSFERS AND , �NHea�TnNCeTnxaEruRn MISC. NON-PROBATE PROPERTY RESIDENT DECE�ENT ESTATE OF O _ J II� FILE NUMBER u� a� � i -�og This schedule must be completed nd filed if the answer to any of questions 1 through 4 on page three of the REVd500 is yes. ITEM DESCRIPTION OF PROPERTY INCLO�ETHENAMEOFTHElRANSFEREE,THE1RRElATI0fJ5HIPTODECEDEMAN� DATEOFDEATH ^/oOFDECD�S EXCLUSION TAXABLE NUMBER THE�NTEOFTAANSFER. ATTACHACOFYOFTHEDEE�fORREALESTATE � VALUEOFASSET INTEREST (�FqPPLIGBIE VALUE � a6�� TOTAL(Also enter on Line 7, Recapitulation) ; If more space is needed,use additional sheets of paper of the same size. . ._ . _, . REV-1511 Hf+(10-09) �pennsylvania SCHEDULE H °E'"RT"""TOF"E�E""E FUNERAL EXPENSES AND rnHea�rnNCe rnx aEruarv ADMINISTRATIVE COSTS RESIDENT�ECEDENT ESTATE OF FILE NUMBER DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s). _ ._ _ _ ._.— _ Street Address_ --.._—_ __—_ ... _.._--- City_ . . _ . _..._State ZIP --_. —__—..—__.. Year(s)Commission Paid: � Z� Attorney Fees: 3• Family Exemption: Qf decedent's address is not the same as c�aimanPs,attach explanation.) Claimant Street Address� � � _—-- City . _.. _.__— ---._.._. __ .._ __ State ZIP Relationship of Claimant to Decedent � 4� Probate Fees: 5• Accountant Feer. � � 6� Taz Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) ; If more space is needed,use additional sheets of paper of the same size. . . . . . � . . . _I _. REV-1512 EX+ (12-08) `i� pennsylvania SCHEDULE I � oevnArweNr oF Revervue DEBTS OF DECEDENT, II rNHea�rnNCe.nx aeruaN 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 expenaes. ITEM NUMBER DESCR]PTION VALUE AT DATE 1 OF DEATfi TOTAL(Also enter on Line 30, Recapitulation) ; If more space is needed, insert additional sheets of the same size. . ._,. _.. .. . . . . . . _ . . . . _ _� . . v REV-1513 EX+ (OS-10) �pennsylvania SCHEDULE ) DEPAqTMENT OF pEVENIIE INHERRANCE TqX RETURN BENEFICIARIES NESI�ENT DECEDENT ESTATE OF: FILE NUMBER: NUMBER NAME AND ADDRESS OF PERSON S RECENING PROPERTY RELATIONSHIP TO DECEDENT AMOUNL OR SHARE � � Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116(a)(1.2).] 1. ENTER DOLLAR AMOUNTS fOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-I500 COVER SHEET,AS APPROVRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUT[ONS: 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. �� R�V-7514 21[+(t2-03} j scHEau� K , LIFE ESTATE, ANNUITY ; C�MMONWEALTH OF PENNSYLYANIA & TERM CERTAIN �� INHERITANCE TAX RETURN � RESIDENT DECE6ENT Check Bax 4 an REV-1560 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for ali singia tffe,joint or succassive Iife estate and term certain caicu�ations. For dates of death prior to 5-1-89 actuarial factors for single life cabulations can be obtained from the Department af Reve�ue,Speciaity Taic Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of deatb from 5-t-&8 ta 4-30-99, and in Aleph Vo�ume far dates of death from 5-1-99 and thereafter. Indicate the type of instrument which creatsd the future interest below and attach a copy to the tax return. ❑ Wili ❑ Intervivos Deed af Trust ❑ Other • ��wf 4M��e`,� �� 11'M 4�q4 .!R °'�T�:'� ❑L4fe or O Term of Years ❑L'rfe or O Term of Yaars ❑ Life or ❑Terrn of Years ❑ life or �Terrn of Yaars ❑ Life or ❑Term of Years 1. Vaiue of fund from whiCh IHe estate is payabie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial Pactor per appropriate table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . interast table rate—� 3 1/2°l0 ❑6% ❑ 10% ❑Variable Rste ._% 3. Value of Ilfe estate(Line 1 multiplied by Line 2) .. ... .. . ....... . ......... . ....... . ....$ • p} nrc0 M � ARE � 3 9 ilOti ry q �#'�� x• �n+" ��.� �; � r � ° �Life or ❑Term of Years O life ar �Term of Years ❑ Life or O Term of Years ' ❑Life or O Term ot Yeare � ! 1. Value of fund from which annuity is payable ... . . . ..... . . ........ .... ..... . . . ... .. . . ....$ 2. Check appropriate blqck below and enter corresponding{number) . . ........ . . . ...... . ...... Frequancy of payout—❑ Weekly(52) ❑ 8i-wsekly(26) ❑ Monthly(12} ❑ Cluartedy{4) ❑ Semi-annually(2) ❑ Rnnualty(i) ❑Ottfer( ) 3. Amount of payout per period ...... .. . ....... . . ...... . . . ..... . . .... .... . . . ... .. . . . . ..S 4. AggregatEt annuai payment,line 2 muftipiied by�Ina 3 ... . ........ . ........ . . ... .. . . . .. .. 5. An�uity Factor(see instn�ctions} IMerest tabie rete—�3 it2% ❑8% ❑ i0°f ❑Variabie Rate °/o 6. Adjustment Factar(see instructlons) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 7. Value af ennWty— If using 31/2%, 8%, 10°fo, or iF variebte rate and periad payout is at and of period,caicuiation is: �ins A x tine 5 x�ine 8 . . . . . . . . . . . .. . . . .. . . . . . . . .$ If using variabie rate and period payoui is at beginning of period, calcuietion is: (LFrre 4 x line 5 x line 8}+Line 3 . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .$ NQTE:The values of the funds which create the above future interests muet be reported as part of the estate assets on Schedulas A thro�gh G of this tax return.The resulting Iife or annuity interest(s)should be reported at the apprapriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size)