HomeMy WebLinkAbout09-06-13 (3) J C� 1505610101
RG{-15ti0 IX{maay �
PA Department of Revenue PM�Y�`/e� OFFICIAL USE ONLY
BureauofIndividuatTaxes INHERITANCE TAX RETURN � Yaem Fi�N '.�
P4 BOx�8o6oi ' �
Harrfsyury,ph i�izg-a6oi RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BEL4W
Sociai Security Number 6ate of Death MMDDYYYY Date of Birth MMDDYYYY
�_ � U 5 � � a LO C S � � t :L�
DecedenYs Last Nams Sutfix DecedenYs�irst Name M!
� � v � �TT�I"TTI�'11 0
(If Appllcable)Enter Surviving Spouse's IMormatlon Below
Spe�se`s Last Name Suffix Spouse's First Name MI
� �� 1��'Ts�"��I YTT1T I T�1 �
Spouse's Social Seaurity Number
THtS RETURN MUST BE FILED iN 6UPLICA7E VV�TH THE
Z � �O 3 - � 5 3� REGISTER OF WILLS
FILL IN APPR9PRIATE OVALS BELOW
� t.Originai Retum p 2.Supplementai Retum O 3. Remainder Return(date of death
priorto 12-13-92)
p 4.�imited Estate p 4a.Future iatere&t Compromise{date of p 5. Federal Estate Tsz Reium Required
death after 12-12-82)
Q 6.DecedeM CNed Testate O 7.tSecedent Maintained a living Trust _ B. Totai Number of Safe Deposit Boxes
(Altaoh Copy of WIII) (Attach Copy of Trust)
Q 9.Litigation P�oceeds Received O 10.Spousal Poverty Cradit(dete of death O 11. Efection to tax under Sec.8773(A}
between 12-31-91 and 1-1-95) (Attach Sch.O}
CORRESPONDENT- TMIS SECTION MUST BE COMPLE7ED.ALL CORRESPpNDENCE ANU CONFIDENTIAL TAX INFORMATIqN SHQULD BE DIRECTEU T0:
Name D me 7eleph�iie Num r�
S Y nI E (a .���(� d�3
=1� TEROFWIt�B ONLY
n d� _ ia
First line of address �,. �ry '"�' <��
�7 ::::,:� _q
-j � ^rl
p � p � ,+ . n
..} _F7 C.� :'" V"�'1
Second line of address :-.i �J� Q
� � [p �1
`v Q
City or Post Oiflce State ZIP Code Dn7E FI�Eo
� S 6 �Z � � 7 ��Z��
CortaspondenYs e-mall addreas: ���
� Under penalties qf perjury,I tleClare thst I have examined this retum,incWEing accompany'mg schbdules and stfltement8,and tp the 48st of my knaMedga and balie�,
� it is irue,corred 8nd complete.�eclarNtion of preperer oUwr than the persanal represeMaUve is basetl on all tniormOUort#which prepsror has any kn�ge.
SIGNqTU�E OF ERSON j3FSP SIBL OR FILINQ RETURN QATE ��� I�
P J
�LV { !
ADDRESS
.�56 �srPo�� Pid S �j�i�eYrs�ttt� IaR t7�S7
SICaNATURE OF PREPARER OTHER THAN R P ESENTA7IVE bA7E
ADpRESS
PLEAliE U$E ORIGINAI FORM ONLY
3ide 1
� 15�5610101 15�5610101 J
�`
� 15056101Q5
REV•1500 EX Decetlert's Sociel Secu�nH}Number
!• �{1n l�Hi- � [ lF ��� +�. i�„ :
De�edeMsName �(/[/]'LI l.- /�' C_.�,
RECAPITUI.ATION e
M1. Rea4 Esfata{3chedvie A). ............................................ �. �.
2. Stor.ks am!Bonda(Schedule B) . .... . .. . .. . .. . .. . .. . .. . .. . .. ... .. . .. . . 2. u
3. Closeiy Hsid Cpr4w�8tiwt,ParfnershiP or Sot�Prai'�Btarship{SchedtHe C) ..--. 3. V � .
4. Mortga9es anA Notes ReceWable(Schedule D) .. ... . . . . . . . . . .. . . . . .. ... . . 4. Q
5. Cash,Bank Deposits ar�d Miscetianeous Persanai Property{Schedule E)....... 5. �� �.
{�! �a
6. JoinUy Owned Property(Schedule F} ip Seperate B��fi^9 Ra9uested ... .. . . 6. �
7. irtar-Vivas Trar�sfs+s&Mlscettan�us Nw�-probate p��e�` �
� (SOheduie G) O SePeratB 8�ReQuested........ 7.
� B. Total Gross Aasds{total Lines 1 through 7)..... .. . .. . . . .. . .
. . .. . .. .. . .. 8. � U '� S
i 9. Funerei Exper�ses and Administrative Costs(Schedule H).. .......... ....... 9. � �
16. Debts of Decedent,MoRgege Liabilities.and Liens(Schedule I) . .. . ..... . .. .. 10. ' u� II
11. Totel DeduetWos(totai lines 9 and tQ)........ .... ..... ....... ......... 41. . � �
F f �
t2. Ne!Value of Estata(Line 8 minus Line 1t) ....... . ..... .. . ......... . .... 12. �. . V � 5 �
13. Charitabte and fiiovemmankst Be4�e�tst��113 Trusfs for whkh � �
an eiection to tau has not been made(Scheduie J) .. . . . .. . .. . ... ... ....... 13.
t4. Net YaFue SubJa'ct t°Ta�t(line 12 minus Line 13j ....... ........ .... ..... 14.�.. � .. �. U 5 �/
TAX CAICULA'f WN•SEE INSTRUC'CK3N3 FDR APPlIGABtE RATES
15. Amount of Line 14 taxable
2S U'19 SQOU58�t8%(2�8,Of n� �,u� �n�� iu �
tf3[t9(8T5 u(Fd91'$eG.911C} ��' u" '��� ' �
- (a)(t.2)X.O.Q. �3 � t, (� 15.
16. Amount of Line 14 taxable 16
at lineel rate X.0-
17. Artwunt of lme 14 taxabie 17.
, at sibiing rate X.12
18. Amount of Line 14 taxable 1�
- at ooAaterel rate X.15
19. TAX DUE . .. . .. ... ... .. . .. . .. ... . . . ... . . . .. .
... ... ... .. . .. ...._.. 19. �� .
20. F7�1 IN TitE OVAL IF YOF7 ARE REQUESTINti A REfUND"#AN OVEtiYAYMENT �
8�42 �
� 1505610105 15056101�5
REV-t500 EX Page 3 File Numbar
DecedenYs Complete Address:
DECEQENTSNAME tf
�1�J_(ti�`(._ _t u�4.L__!� � --.
—— ----- —_ . ------
STREE A pRESS
�—��rg�c�- — - ----- _�. --- ---__--- --
--w — -__--_
an `_�� _ srnre ��'-iiP__—_
—T 5
Tax Payments and Cradits:
t. Tax Due{Page 2,Line 19) {�} R ��
2. CrBditslPayments
A.Priar Payments ---.4 �.__
B.Discount
— � � FWa!Credits(A+B} {2} �O
3, Imereat s
(3) . 0 tl
4. If Line 2 is greater than Line 1+�j�3,enter the diflerence. This is the OVERPAYMENT.
FI�in av�oo Page 2,L.ine 20 ta request a refund. {4)
5. If Line 1 +Line 3 is greater than Line 2,enter the diflerence.This is lhe TAX DUE. (5) . Q(J
Make check payable to: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE 9LOCK5
1. Did decadent make a transfer and: Yes No
a. retain the use or income of the ProPenY transierred:.......................................................................................... Q �
b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ [�
a rehain a reverswnary interesQ or........................................................................._........................................,...... ❑ �
d. receire the promise for Ii�e of either payments,6enefi#s flr care?...................................................................... ❑ �
2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death
wNhout receiving adequate consideration?...................................................... ❑ 0
........................................................
3. D!d det�ent rnm an�n bust fa'rn payabie-upcm-�ath bank aaount or security a#his or her death?.............. ❑ (�
A. Did decedent own an individual redrement account,annuity or other nao-pro6ate propeAy,which
rxmtainsa beneflciary designation7 ........................................................................................................................ � ❑
{F THE ANSWER TO ANY OF THE ABOYE QUESTIONS!S YES,YOU MUS7 CBMPIETE SCHEDULE G AND FILE tT AS PART OF THE REiURN,
For dates of death on w afler July 1, i994,anci bef4re Jan. 1, f995,the t�rate impased on the r�et value af trar�sfers ta or for tlie use af ihe surviving spouse Is
3 perce�t(72 P.S.§9116(a}{1.1}(i)].
For dates of death on or after Jan. 1, 1995, the ta�c r�te imposed on the net value pf Uansfers W or for the use of Hre survivirrc� spouse is 0 percent
j72 P.S.§9118{a}{t.t)(u)}.The statute does not exempt a transfer W a surviving sp4use from taa�,and the statutory requirerr�nts fw discl�sure of assets�xl
� t�ng a t�retum are s67f appiicat�e even if tt�surr�g spouse is the only bene6ciary.
For dates of death on or after July 1,2000:
. The ia�t rate imppsed on Ihe net value af transfets trom a deceased child 2i years of age or younger at death to a fqr the use of a naturdi parent, an
adoptive�rerrt ot e stepparent of tl�e t�ld is 4 percent[72 P.S.§9116(ax12)j.
• The t�uc rete impnsed on the net vaiue of transCers to or for the use of the decedenPs lineal ber�eflciaries is 4.5 percent, except as noted in
72 P.S.§9116(1.2)(72 P.S.§9116(a)(1)1•
• The#a�t rata imposed ati 1he rtet vaiue of hansfers to flr�the use of the decedenPs sibiin�is 12 parcent(72 P.S.§9416(a}(1.3j].A siblittg is defir�d,u�
Section 9102,as an individuai who has at least one parent in common wifh ifie decedent,whether by blood or adopdon.
• REV-i5o8Ex+(�.i-io)
� pennsylvarria SCNEOl1LE E
� DEPAN'MENTOFREVENUE CASH, BANK DEPOSITS & MISC�
r""ER,T""«T"x i�TUR" PERSONAL PRBPERTY
RESIDENT DECEDENT
ESTATE OF: ,� �� t FILE NUMBER:
_ Y� v�an � tve� te.�-/
Include the proteeds af liYig � n and the date the proceeds were reteived by the estate.
AII property jointly owned with right of survivonhip must be diaclosed on Schedule F.
REM VALUE AT DATE
NUMBEft DESCRIPTION 6F DEATH
1 �rrS�Uhrn oP An.k Cher,�f'�n� aCC �u.�� �{U 5�� St�
TOTAL{Also enter an Une 5, Recapitufation} ; �(�� q .S�j
if r�wre space is needed,use addlfionai sheets of paper of ttre sams size.