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REV-1500�`{�-'i,��,
_ OFFICIAL USE ONLY
PA Department of Revenue P�Y��a Coun Cade Year Fie Number
��,��:rt� ty
Bureau of Individual Taxes INHERITANCE TAX RETURN - �...._ . _. . _...... . _
Po BoX z� �1 I � l��v"
Har�sburq,PA i�u8-o6o� RESIDENT DECEDENT
_
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMODYYYY Date of Birth MMODYYYY
'-�� �_` ' ;�? �`�_ � a_��-2- 'd_� d_� l�' /�,`�'"._,
_ _.
DacedenYs Last Name Suffix DecedenYs First Name MI
_��._.�-!..i�''��-�.�.,. s . _ ___ . .s_ ._... __ .�,--5' �'-� .��'-<',.C. .�__ _ _ __ ._ .S
(ff Applicable)Enter Sunriving Spouse's Infonnatian Below
Spouse's Last Name Suffix Spouse's First Name MI
`���'i _ _
_ _ _..,____,,.._,,,_,
_...... .......... . ....... . _......._ ......_.... . _.... _.._._.
.._..._:
Spouse's Soaal Secunly Number
„ _ __..._ __,_ __,__._, ____,__„,_. ___ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
____._ ._ ___. __ ____ _ REGISTER 4F WILLS
FILL IN APPROPRWTE OVALS BELOW
�j 1.Original Retum p 2.Supplemental Retum O 3. Remainder Retum(Date of Death
Prior to 12-13-82)
Q 4.limited Estate Q 4a.Future Interest Compramise(date of O 5. Federai Estate Tax Retum Requir+ed
death after 12-12-82j
O 6.Decedent Died Testate O 7.Der.�ent Maintained a Living Trust 8. Total Number of Safis Deposit Boi�
(Attach Copy of Wtli) (Attach Copy of Trust.) �, �:,� �
O 9.Ldigation Proceeds Received O 10.Spousal Poverty Credit(Date af Death O 11. E l���n to Tax under�Sec.9133fAj�
. Between 12-31-91 and 1-1-95) (A S"c�edule O) �- �:;�, �
. �..y
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATtOI�3H0U1�D�8�L31RE�CTED T0: :'�1
_.,
,.
Name Daytime Tel one.Numberr�� . '
_......... ............ .___ ____. .__.__.__ ______, ._____.. __,__ . _ ___._... _.._._ _ _ _ _..
__... ___.
_ __...... __..__. _.___,. _ _.._ �, . .t_,_. ..... �
�'�T�.Erj�'�-�`.�' _.._ �_ . .__�'a�'�'� ___ _ . �'`� ��'?: :-._�:�. ....�-�'-~i`�
_
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REGISTE"�R OF YVLtrS USE ONLY '�
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First Line of Address � ' ��
_..... �.. .......................... _,_ _.. _...... .______.____ .....-
� _..,.___.__.,_..,.,.._._..............__._..,__.__ �: r
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� ��.��o?..��-1�....-��-':�'. . _.��..-��G-�-. ...�.,.,�..._......._.._._.. _.
Second Line of Address
_ _.__. __ _..._ _____. . ...._.._ ..._._............_.... _.._ ____.__ _.. _. .._.__........ ______....
_ _. _ __.._.. .
�...._.._. ._............. .._.._.._.........._.._.._
_....._...
City or Post Office State ZlP Code DATE FILED
,r-`� �G�i�`��, J,��'/�.S�.��..��-�. ....., �/� . J_�C�_ �"rU.____
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Corresponde�rt's e-mail address: �'_--~ ��
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Under penalties of perjury,1 dedare that 1 have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,corced and complete.Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG RE O�PERSON RESPON E FOR FILING RETURN DATE
sr2.��/�G`l Q�. ./"� -.��i�� /.3
ADDRESS
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
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ADDRESS /
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. PL SE USE ORIGINAL FORM ONLY
Side 1
� 15056101�5 1505610105 �
aEV-uoe Ex+(os-u)
' pennsylvania �ME01/LE E
DEPARTMENT OF REVENUE CASH, BANK DEPQSIT'S 8E MISC.
INMERITANCE TAX REIURN pE�q�,pROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
�o��_�'..{!-G�' .� ��v ///.� �C.� v�//� --/�o?.��
Include the proceeds ofiitigation and the date the proceeds were received by the estate.
All ProP�Y]d��1►ownad with right of survivast�p must be�cio5ed on Schedule f.
�M VALUE AT DATE
NUMBER DESCRIPTION OF DEA7H
�� _��e.�- , -�-'' .,k���� � �. : ��'��r ,S'';�.,
�-��
, �
: _ _
TOTAL(Aiso enter on Line 5,Recapitulation) ¢ , ���c�, �'
If mare spaoe is needed,use addi4onal sheets of pa�r of the same size.
REV-1511 EX+(10-09)
� � pennsylvania SCHEDULE H
bEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
�'..`1�',/����:,,��" .5". �� 1/�/� �G...� � 0�1'/�0� - ,�'� �? S�'
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTIdN 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:
2. Attomey Fees: "�
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanaaon.) (.._./
Claimant
Street Address
City State ZIP
Relabonship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7. _ _ __ _ _ __ __ _ _
TQTAL(Also enter on Line 9,Recapitulation) � �
If more space is needed,use additional sheets of paper of the same size.
• � 1505610205
REV-1500 EX(FI)
DecedenYs Social Security Number
DecedenYs Name: '
RECAPITULATION
1. Real Estate(Schedute A). ............................................ 1. 'i � '
2. Stocks and Bonds(Schedule Bj ....................................... 2. C�
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. ; v
4. Mortgages and Notes Receivable(Schedule D)........................... 4. � .
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. d �
.-�� �' . . s. � _. _
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ' (,�
�� __�...__,. „____:�_ _.,,_.__ ,,.,_, ,_,,.._,._ __,..._ _.
7. Inter-�vos Transfers&Miscellaneous Non-Probate Property �
(Schedule G) O Separate Billing Requested........ 7.
�.,. .,___ �._„_, _ ,.. _.,... �..,.s.._ ...... ._._
__
8. Total Gross Assets(total Lines 1 through 7)............................. 8. �'
�� . �S e�-�
9. Funeral Expenses and Administrative Costs(Schedule H).............. ..... 9. / �
... ....... ..... :(_.�/... _.
; 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. 'i v
_,A_�_._.,,,.,�._ ,.�,_.�,�__._�_._. __.,._,_� _ .,u_..._..
11. Total Deductions(total Lines 9 and 10)................................. 11. : �
12. Net Value of Estate(l.ine 8 minus Line 11).............................. 12. ��`�Qr
_..... __....__ ,......_. �,-� ......,.__.. ...
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which U
' an election to tax has not been made(Schedule J) ........................ 13. '
` 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. ��G d, �--��
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.
� �._. ..., _.�: , ....�_��.. ,..,,.�. , _..b:.� . ., �mFU. �_.�,a�...M..; m.�... .,..H. , _,.. �e.x._ ......... ........._ . ......_,�.. ...,�
16. Amount of Line 14 taxable
at lineal rate X.0�/� .�/ �' �� ; 16. , � �
/��
.,.__,. _.___._., __,�_u_.._^,..,_._�,_ ,,._ .,�... .__.,.__,., ; �_,., . ....r_ ,. _..,,., . .,.�. ...._,.. .. .�__ „__�,., _
17. Amount of Line 14 taxable �
at sibling�ate X.12 17. '
...., ,...,... �..:..,...,..,... ...,........._.....� .._. , .... . ,.. . ...,. .:..�.. ..,....... ....
18. Amount of Line 14 taxable �� ' '
at collateral rate X.15 18.
' 19. TAXDUE ..............•---....................................... 19. �1��,` �v9.�
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 150561�205 15056102�5 J
.
.
, f2EV-i.500 EX{FI} Page 3 FNe Number
�Decedent's Camplete Addr+�ss: ,�'' �r�� --� /c�� s'"'�
DECEC�ENTS NAME
�'� ��',�',f�` �`, ..�� t/.� -�
STREET ADDRESS
�.�.� ' �
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�� rr'`�-.-�
CITY � STATE ZtP
'GG%�,,-��.�� � ..a.. -`'�.�' /''��.l s�.�`
Tax Payments and Credits:
1. Tax Due{Page 2,Line 19} (1) o�/�c'�'• .."��
2. CreditstPayments
A.Prior Payments
B,Discoun#
Total Credits f A+B) (2}
3. Interest
(3j
4. I#t�r�e 2 is greater than Lir�e 1+Line 3,enter the di#ferenee. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is gnaater than Line 2,enker the difference.This is the TAX DUE. (5) ��"'��.' ��
Make check payable to: REGISTER OF WILLS,AGENT.
.. '�,,� � 3TM.'-:a � �4 b;: � �,^�� AE a �, <2- ;:�,� �`' °� ..*: '��,.: .. ..�� �s .;:..; .�.; � ��:5 2 .,,�q .�..�i,� a*E"�,�' 'n �
�ca z.��. i c � i , .�. a u � ,n
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5 fi t
PLEASE ANSWER THE FC1LlOWING QUESTI�NS BY PLACING AN"'X"iN THE APPROPRIATE BLOCKS
1. Did decedent make a t�ansfer and: Yss No
: a. retain the use or income of the praperty transferred.......................................................................................... ❑ ,..�'
b. retain the right ta designate who sha11 use the property transferred or its income............................................ ❑ .�]
c. retain a�:versionary interest.............................................................................................................................. ❑ .�
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 o#dea#�
: without receiving adequate considera6on?.............................................................................................................. ❑ �
` 3. Did decedent awn an"in trust for"or payable-upon-death bank account or security at his or her death�.............. ❑ �"
4. Did decedent own an individual retiremenE account,annuity ar ather non-probate property,whic�
: contains a benefiaary designation? ........................................................................................................................ ❑ "�
IF THE ANSWER TO ANY 0�THE ABOVE QUESTt�NS IS YES,YOU MUST C4MPLETE SCHEDULE G AND FIIE IT AS PART QF TNE RETURN.
.x�,eF�, 3'v,,���k'-�`:�,:r da .,i,�,c,z x-�. �,Y=.,•> ,"^` �:� � s :,g a+ ''_-z_N.:i s� �es: '' '`� ,�s ;.:r� a�, e.,,� ��
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For dates of death on or after July 1,1994,and befare 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[?2 P.S.§9116{a}(1.1)(i)j•
For da#es 4f death on or after Jan. 1, 1995, the t�rate imp�ased on the net value of transfers to or far the use of the survivirt� sp�s� is 4 perc�nt
(?2 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a fiansfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filir�g a tax retum are still applicable even if th�e sunrivir�g sp4use is the aniy benefrciary.
For dates of death on or after July 1,2(}00:
• The#a�c rate imposed on#he net vaiue t�f transfers fram a deceased child 21 years of age or younger at death to or�Or#he use of a naturai parent,an
adoptive paren#or a stepparer�t af the child is 0 percent[7�P.S.�9116�a}{1.2}].
• The tax r�te imposed an the net value of transfers to or for the use of the d�cedent's lineal beneficiaries�4.5 pement,exoept as noted in�12 P.S.§9116(a�(1�].
. The tax rate imposed on the net vaiue af transfers to or far the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)j.A sibling is defined,
under Section 91�2,as an individual who has at least one parent in common wit�the�i+rcedent,vuhether by binod or adoption.