HomeMy WebLinkAbout08-05-13 J ,i 150561�105
R��'i �/1/1Ex(axns){Fry�rj
i H\/ Yi CFFlCUL U8E ONl.Y
PA pepartment of Revenue DeW+!�Y��a
BureOU af Individual Taxps "` "`°`"�` Caunty Code Year FJe Number
Po60x28o6oi INHERtTAMCETAXRETURN
_ Hamsburq,PA i�u9-o8oi RESIQENT DECEDEN7 a� j � � j ���� I
ENTER DECEDENT INFORMATION BELpW
Social Secunty Number Date of Death MMDDYYYV Date of Birth MMDDYYYY
� _ � o� -o� ►'� —J I °3 ~o' " �gys __�
DecedenYs Last Name Suffuc Deoeden£s first Name MI
..� _.,_4. .___..._ T_ -_..
_...__... . ._____
(. l-4o�5-n�� __- ---- -- !`___.--1 i--Lo�tS� -- --- I�
{IP Appifca6�e}Enter Survlvittg Spause'a InformaHon Below
Spouse's Last Nsme Suffrx Spouse's First Name MI
T _ —._ ___ ._
C __ . -� ' _ i i__-----__--__ _____� '__�
Spouse's Soutiai Securiry Number 7HI5 RETURN tdU3T BE FILED fN DUPt►CATE WITH THE
_ _ �� REGISTER l?� WILLS
FILL IN APPROPRIATE OYALS&ELpW
_ 1. Original Retum p 2.SupplemenWl Retum O 3. RemairWer Retum{Dete of Oeeth
Priorto 12-13-82)
p A.i.lmfted Esiate Ci 4e.Future interest Compromise(date of q 5. Fetlarai Estate Tax Return Required
daath aftgr 12-1F-82)
O 6. Decedent Died Teafate O �. Decedent Maintained a Living Trust _ 8. Total Number ot Safe peposit 8ozes
{Attach Copy of Wfli} (Attach Copy of Trust.}
O 9.Llligation Pmpeds Recaivetl O 10.Spw�sai Pqverly Cretlit(Date af Death O f t. Election#o Tax untler Sec.9113(A)
Belw9en 1231-91 end 1-1-95) (AttaCh Schedule 4)
CORREBPONDENT- THI$SECTION MUST BE C4MPLETEp.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFpRMAT10N SHQULD BE WRECTED 74:
Name Daytime Telephone Number
__.._. _—.�.—.. _`._. _.�.__.—.. ._—..-�...�_—_
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� �ER OF Wi�S U88'Ri�
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Fitst Line ot Address
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Sacond Line otAddress a c� � � -ar '"�
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't�Z �J • I�'R-I�NE ST12.�G'� _�� � � � '
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tCf y or Post ORice ^T� State Z!P Code � � DATE fl►ED r
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CorrespondanYsamaiiadckess: ��'^S5{JS� tl2v4��'"t �nft-
Undar penaltk�s ot pgr}u7.I�Gare that i M+re exemi�etl Ws retum.ind�armmparrying scheAW�and atatements,arM io tM1a best of my knowiedqe and baliei,
it is hue ct and cpmplete.peclare[lon of preparer oth9r Nen Me peBOnal representalive is based on all IMOrmation pt whlch preparer has eny krwwledpe.
S16N R OF E O S OR F1 RE7URN DATE
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ADDRES !� � /� �/ Yp1III �'\ C � �V����1 ` ! `-'s�
�1 /il �[
S16NAlU F PARER�ITHER R PFtEF� F{JS TA^TIVE DATE J(q�j�Z
�Y�� �..._�ir� 8-� `C�' c �
ADb S
�•(;�•d�.� CQ315} Z.'"� S- c�-4�.r,c.5�4� r I� a�,-�atx.�y � V3- I ��iz -�sis
PIEASE USE ORIGINAL FORM ONL
Side 1
� 150561�1�5 7�SQ561�1D5 �
� 1505610205
REV-7500 EX(Fla
Decedeni's Sociai Security Number
oecedenfs Name: LVV�Xi �-+��Z.��- 4 ,`"����- +�
RECAPRULATION
__.___. __..._ .__ ._.._.,
1. Real Estate(Schedule A). ............................................ 1. I �
2. Stocks and Bonds{SChedule B) .. . ... ... ... .. ... ......... ....... ... ... 2. �. (
3. Closely Held Corporetbn,Partnership or 5ols-Proprietorship{Schedule C) ...._ 3. � (
4. Mortgages and Notes Receivabie(SChedule D}.. .......... ............... 4. � i
5. Cash,Bank Deposits and Miscellaneous Perso�al Property{Sahedule E)....... 5. � o�,�� + �`Z..Z...- `�' �
6. Jaotty Owned Arpperty{Schedula F7 a Separate Billing Requasted .... ... 8. ���`�
7. Inter-Vivos Transfers&Miacetlarreous Non-Probate Property
(Schedule G) O Separete Billing Requested........ T. � i q �} � °u ��
4 � �
8. Total Groas Assets(Whai lirres 9 through 7}............ ..... ............ 8. � ra'Z '7 r� �{Z.Z . °v !
9. Funer�+i Expenses and AdministraUve Costx(Schedule H)........ ..... ...... 9. '' ( 'Z � ��'�? Q I
. i
fQ. Qebts of itecadant,Mortgage�iabiiNes and Liens(Schedule 7}............... 10. � � Z,�, . .
�� � �
11. Total Deduetlons(total Lines 9 and 10J.... ... .......................... ri. �y �t}S .S% i
72. Net Yalue af Estate(lane 8 minus li�e tt}.............................. 12. � o�+ � !� �- I t0 � s'" (
73. Charitable and Govemmental BequestslSeo 91i3 Tntsta for which �
. an eleCtion to tax has not been made(Schedule J) ................._..... 13. � �
74. Net Yalue SubJect W 7arz(Line t2 minus i.i�13} ........................ 14. � a 5� � �, t Lp� 5„vi I I
TAX CAICUlA7tON-9EE IMSTRUCTIONS FOR APPIlCABI.E RATES
15. Amount of Line 14 Wxable
atihe apousaitax rale,or
i6. Amo nt of OLane 1�4 taxab e ir_._.__ .._... __.. � 15. ...._._ ..__._. ._.___ -�
at iineai rate X.o_ 16. _` �
'17. Amount af Line t4 taxabie F So � � .�� ��
at sibling rate X.12 I a s�,a, �� � � ». 3o q S• I
18. Amount of Line 14 texaqle �, I
at coifaterei rate X.15 '�� 18,
iv._"._'_-___.__'__._.__._�
^�� p P
19. TAXDUE.... ............. ........._........_...__..._....... 19.� Gl"i `t�S '�'' J
20. FiI.L IN THE 6VAL IF YOU ARE REaUEST7N6 A REFOND OF AN OVERPAYMENT O
Side 2
� 1505610205 15L1561�205 �
REV-�5�k EX jF(j Page 3 Flle Numbu �, ^ + 2 _ ��O
Decedent's Compfete Address: '
DECE6ENT'S NAFdE
(.,.oC�1S� C�,4s�,. ��S1lL�
STREETAQDRESS �/� �j j}
� �U� U'ti V"��. '4J � �U f�-
cirr VYl£G-N{�tv�.51GSPSc.�(o srnre � Z1P t�oSS
Tax Payments and Cred(ts:
1. Tax Oue(Page 2,Line 19) {t} �p� ��S�• �
2. Gredits�Payments
A.Pnor Peyments _
6.Discouni
Total Credils(A+B) (2)
3. Interest
C�)
A, if Line 7 is greater than Line 1+Line 3,enier[fie difference. This is the OVERPAYMENT.
PIII in ovai on Page 2,line 2t}to req�st a retund. (dj
5. If Line 1 +Line 3 is greater Nan Line 2,enter the diNerenae.7his is the TAX DUE. (5) ��t c��s,4�
Make check payabie #o: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLLOWMG QUESTIONS 6Y PLACING AN"X" IN THE APPRQPRIATE BLOCKS
i, Did decedent make a Vansfer and: Yss No
� a, relein!he use nr ind5me of the properry trensferred.......................................................................................... � �
b, reiain ihe right io designate who shail use ifie property trensferred or its income...................................._,..... ❑ �
e. retain a reversianary imerest.............................................................................................................................. ❑ [�
d. receive the promise fa iife�eRher payments,benefits a care?...................................................................... ❑ [�
2. !f death occurreG after Dec.12,19B2,did decedent transfer property vrithin or�e year of death
witheutreceivingadequatewnsideration?...................................._....................................................,................... ❑ - �
3. Did decedent own en"in trust for"or paya6le-upon•death bank eaount or security ai his a her deathl......._..... ❑ m
4. Did decedent axn an individual retirement accaunt annuily or other non-probate property,which
contains a beneficiary dasignationl .................................................................................................................._.... ❑ �
IF THE AN5WER 7Q ANY 4P THE AB4VE QUESTIONS IS YES,YOU A9UST CQMPLETE SCHEdULE G AND FILE IT AS PART OP TNE RETURN,
For dates of death o0 or after July 1,1994,and before Jan.i,7995,the tax rats impos�on the net value of tranxfers ta 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 aRer Jan. 1, 7995, the tax rate imposed on ths net value of transfers to or far the use af the surviving spause is d percant
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer ro a surviving spouse trom tax,and the staWtory requirements tor disclosura of asseks and
filing a taz retum are still applicable even'rf the surviving spouse is ihe only beneficiary.
For dates af death pn or after July t,20d6:
. 7he tax rate imposed on the net vaiue af transfers from a deceased chiid 21 years oi age or younger at death to or for the use of e natural parent,a�
adoptive patent a a stepparenT of the child is 0 percent jT2 P.S.§9116{a}(12)j.
. The taic rata imposed on the net va(ue o#transfers fa ar for the use of the decedenfs Iineal benefiaiaries is d.5 percent,except as nated in[72 P.S.§9116(a)(1)].
. 3'he tax rate imposed on the net vaiue of iransfers to or for Ihe use of the dacedenfs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
u�der SecGon 9142,as an individua!who has at least one parent in comman witt�the decedent,whether by biood or edoptlan.
REV-1513 IX+(01-10)
` P��sYE�ma SCHEDULE ]
OEP�RTMEXT OF PEVEXUE BENEFICIARIES
INHERITAN<;.8 TA1(REIVRN
RES[DENT DECEOENf
ESTATE tSF: 1 DU��SE. �a f�2.�.. I��IIGK-� FIIE NUMBER:
!.. Z�-'I 3-CW D r���
REUTIOMSttIP TO DECEDENT AMWNT OR$HARE
NUMBE{t NAME AND AO�tESS#FfR50N{S)RECEIVIN6 PROPER7Y pp!I�Ltat ttu�iae(sj OF fSFATE
I TAXABLE p151RIBUTtONS[Include outdgM SDOUSai disMbutions end tmnsfers under
Sec.9i16(a)(1.2).]
i. „�Ate- t�• 's�Ou�stc�. b rd��e,.- !co�
�1.� N�M i�b '�7qe�
{�au� , '�G l99p1
ENiER DOLLAR AMOUMI'S FOR DISTRI9UTIONS SHOWN ABOVE ON ltNE515 7HROUGH IB Of REV-1500 COVER SHEET,AS APPROPRiA7E,
B NOH TA%ABGE D15TRi6UTi0N5
A. SP6USAL DISiRtBUT70N5 UNDER SECitON 9113 FOR WHICH AN ELECfION TO TAX IS NOT TAKEN:
1,
8, CHAAITABLE AND COVERNMENTAL DISTRIBNIONS;
i.
T6TlU QF PART II-£NTER TOTA!tHkl TAICABCE DfSTRIBt7fI0tt5 41�I LINE 13 OF REV-1560 COVER StIEET. �
If more space is needed,use addidnnal sheeGS qp paper af the same size.
� NEWi5o8IX+(o8-u)
�pennsylvania BCNip11LE E
omannnianoFr�veuE CASH, BANK DEPOSITS$MISC.
�r�oc�� PERSONAI.pRppElny
��,��: �ou �s�
G A L� 1-40 2sT�c� ��nx�:
►�����r a I - 13-on4o
�wev�r ior�ur o.�e�rq�i,e d a�ce'ne w�w�re re�d ny nK�.
� +���v�.c�ardo.aa on sa�.aue F.
N�MBBt pE�pR� VAUIE AT DATE
oF o�ni
1. W�IIS �cv�o 'PYYIV} Qr�m4� Chf.�4� a
2. ����5 �-o-r�o �-Fil.�� � If��G� �"'� ZC( ' 7��,! 'a'
3. W���S �21 o Wa� Z sa✓t. � C
u
murcl �55�-�- � � �4 5'�a>
`( . 1��c11S 'Fu,-�° �°vr' m�-�a�-, 5 y� 5-�y , m
s� Lt��.0 U
s �'r1° S�l°.-A '�rok�.��e— 1 3 3 �z i . �
� W4.Ils �o Sf��lA�d �ijvb�-F..-�� 3y ,� zzo.�..�
7. I a95 Cl��ro��#- Lvm�,�.- 1 , o00 .�
� . �I��W l �o�.t lo�l��,��, S�,w
ror�u�a�o�«,u�s,r+�qna�„� s a,s 3 c�u,�
If rtqre space k neMed,use addtlaial�M paper af the same siae.
REV-1510 EX+ (08-09)
� ���a SCHEDULE G
� OEPMTMENTOFpEYENUE INTER-VIVOS TRANSFERS AND
'""�""�T"'�"E""" MISC. NON-PROBATE PROPERTY
aESOexr o�r
E5TA7E OF FILE INMIlER
LD V�S� Cl hLf! ��'�ST���-
�e+3-=�eas'-Ee Zl-I�-oal0
This sdKdWe must be ampleted and fded ff tl�e a�er to am'd quatlons 1 thrwgh 4 m page tlmee d the RE11-1500 is yrs.
� DESCRIPfION OF PROPERIY
en�nen[wvEavnEnwsee,naraama�roo�ertxo WTEOFOEAiH %OFOENS IXCLUSION TA%11B1E
NU7BBl nEUaEanNea.ann�emrranEO�rm�erae VN.UEOFASSEf IN16tE5f VAWE
1. Sau�r� t�onJ.s. — JAc.K- I�s�,tk. R�Soo,w �o�7a �{/S� °�
s� a.�}�hctit s►��t-
� `..xiu�l.� bo� ' �a✓�.� �,ou f—�auS �c{£C'Ea,S��� q��'� /QD�o li�JD,o,�
I SE� Gc�ty�y� S(�4./'
TOTAL(Alw mter on Line 7,RecapituWtron) $ � ��Op 0.00
If mae spaa is needed,use addidanal�d paper of the same size.
�vucs� C`aA,.,4. ��o�-S'�c.�- aG - i �~-ooNo
SAVINGS BONDS
.i14{�C A FIORSTICK NIARY lOU KCAUS
155UE DATE SERIAL NUMBER ISSUE DATE SERIAI NUMBER
02 2000 D518b913HH 02 2001) 0528b894FlH
02 2000 D51$5914HH Q2 2000 D5186895HH
02 20bQ D5186915HH U2 200Q D518fi896HH
02 20�0 D52$69i6HH 02 2004 D5186897HH
02 200Q D5186917HM 02 2000 D5186898HH
Q2 20Q0 D5186418HH OZ 240a D5f8b899HH
02 2000 D5186919HH 02 20b0 D51$6900HH
d2 20t14 DSf86920HH 02 2000 D5186901HH
02 2000 D5186421HW Q2 200U D5186902HN
02 20QQ D518b922HH 02 2000 D5166903HH
d2 200t) D5386423HM 42 2000 D5186904HH
02 2000 D51$6924HH 02 200i1 D5186905HW
02 2000 Q5186925NH 02 200Q d51$69U6HtI
02 2004 D5186926HH 02 2000 D5186907HH
42 2000 D5186427HN 02 240p D5186908HH
02 200d D5186928HH 42 20QU D51869Q9t#N
02 2000 D51$6929HH 02 2000 D5186910HH
02 2flOp D5186930HH 42 20�0 D518b912ttFt
02 2000 D5186931HH 02 2000 D5166912HH
t�v-iui ex+ �io•o9�
���,��;� SCHEDUlE H
��� OEPARTMENt OF pEVEOUE ��NEi{/iL EX��`lG�l1 If�Y
TM'�"*,'"�7A1�"» ADMxNrsrR!►3zvE cosrs
�r ocr.e�err
Esra�oF �ou� �+{�.,- ,�oR-s�k.K- �a�g,�..@.�2as�t. 2.I-�3-a�(a
Daaeienc's Aebd�epNt 6e nps�W on Sd�adWa L
11Hi
NUMBEA DE5aUVfiON ANOUNi
a. FUNERAL EI(PENSES:
i. 1�4�+'�'LI�- ' l�,i�t�E✓ �erwe ,�o rYt�c �o �ODt2 . c�
a. ADMINISFRATSYE COSTS:
f. PasawF P.�SentMrve Camm�sions:
i7ame(s)oi Msa�ai Repre�ntadve(s)_,_.,._—_—_—..-------�,__...
Svt�e[Address_.._-..--,_ . .._---_ - ------.. . __----_ . .�_.___. .__._-------_
�f' __,.-------------------�-------�-----�-.._--_—___.__ �
Year(3}C.mrcni�on P2id; �
2. AttomeNFe�: �Nru,_, yY'�. '�t}Ufot�11�" ,SJ ppC7 . C50
., �
. 3. famtly 5unipSion:(If decMent's adCress s not tl�e sxne as tlahna�R$,�eq+lanatiat.} .
oaimaM
Street Mdress
�`!_.___._...- ..__...—.._.—�----__-----------_.�-.._--�P--------
n�a an�ar�c m o«�e_
4. Mobate Fees: �O�'• Sa
5, AcmuMantFees: (,j,J�Z.a�.£vMCtVI � """"'`{ � �'�"' 1.�'y0 •CJ�
6. Tax Rdum Prepgrer Fees:
'. yn;��e- C� aoo m;l�.s ��3.io (ot�o •
O�
�-. ��cu�-nx- c1�.��w t9ay �+s J � g•�" � h�, �qz, a�
0
� • A(� VE✓�ist� Sbf� , o�
t0. �t>S��`� ,r,�'p• a='
TttTAt(l�ksa eMer on tane 4, � } Z �� ��p"p .'�j�
tf�re�a�needed,use ad�tla�shee�M paper af tht sm�re sF�e.
. . �
aeuisrz ex+�tz-ia}
�penns�rtvania SCHEDULE I
���� �a'rs oF u�cEU��tr,
na�,TU,�r,uc� MOR76AGE�*sRt�*Tr�$LIENS
x�xt o�o�ttr
esr��oF �auES� C-�A�,E� �-ivR.�ct�- �� zi-��-cx,�.�o
a.�«T aauer i�ne ry ua ae��C v�a e.W�aK.am�i aqMa n ui.r.oe d Ia.ny�n��4p�ri.rr..�wr�o��qs�et.
TiEM VM.VE AT DfiE
NUMBER QESCHIPROM UF DE#Tii
i. ��- — .�q,yWCC�i,� '2.Cy73 ..,`�J'r,,,h f`�t�yyyyYyc..�uv" t11� m
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2_ 1�sp,��. � C4,V,t*�.1 'P�- �-`�,, °°
,
TOTItI(iVso eirter on Line lU,wKaqu,�l # ( LZ�oo
8�e�sac is needed,xrsdt aa�ttonai sheets af the same s�ze.
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