HomeMy WebLinkAbout09-06-13 (2) � 15d5610101
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REV-1500 ����Y
PA Department of Revenue P?�!�sYt'��? County Code Year Fife Number
Bureau of IndiWdualTaxes INHERITANCE TAX RETURN
PO BOX z8o6oi � � � �
HaMSburg,PA iTiz8-oEws RESIdENT DBCEDENT
? �/� v8 1 / o o � � J !
DecedanYs last Name Suffix DecedeM's First Name MI
►a r ��I�,Z� �1
{NAppilcabie}EMer$urviving Spouse's Infarmation Balow
Spouse's Last Name Suitix Spouse's First Name MI
� ���X�� ❑
Spouse's Sociai Sscurity Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
r�r�eTrD REGISTER OF WILLS
i fllL IN APPROPRIATE 6VA�S BEtOW
� 7.Original ReNrn p 2.Suppiemental Retum Q 9. Remainder Retum(date of death
priorto 72-13-82)
p 4.IJmited Estste p 4a.Future intersst Gompromfse{date of p 5. Federa4 Estate Taz Retum Required
death after 12-12-82)
p 6. pecedent Died Testate Q 7.pecedent Mairiteined a living Trust _ 8. Total Number of Sate Daposit Bpxes
(Attach Copy of Will) (Attach Copy of Trust)
Q 9.UtigaUon Procseds Rect+ivetl p tfl.Spousai Povsrty Credit{date M death O 1h. Election to t�u�er Sec.9tt3(Aj
betvreen 12-31-85 and'I-1-95} {Rttach Sch.6}: � �
CORRESMIN�ENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFpRMA�N SHOUL¢�E DI , T�TO:
Name Da e�llephane�kumber:' ��
A 6 ' l
H RE��S�R OF 1MLL3 BNE� LY
G7 r-. , _.y
� -
(^) "��' ' . , a��
First line oi atldress c:� �.� � �, ,;s
N u n i n o r1 v `-� =+ �, �;� �a
� �
Second Iine of address
City ar Ppst OHice 3tate 21P Cade 6ATE Fl�ED
= n 1 � 1 7a �
corresponaeM�s e-ma8 saareas:
Untlar penalties of perjury,I dedare that I have exemVnetl this retum,inGuding eCmmpanyinp schedules and statement8,and to ihe dest of my knowledge and 4elief,
il is We,cortecl end cDmplete.Decler9tion of preparar oUer than Me person0l representative is basetl on ell infortnation of which preparer has eny knowledge.
SIGNATURE OF PERSON RESPC7N9IBLE FOft FIIiNG RENRN DATE
ADDRESS
SIGNATURE OF PREPAREft OTHEft THAN REPRESENTATiVE pp7E
ADDRES3
PLEA$E USE ORIGINAL FORM QNLY
$ide 1
L 150561E1101 1505610101 J
�1
J 1505610105
REV-1500 EX
DecedenPs Sociat Security Number
Decetlent's Name: �� ��
RECAPITULATION
1. Real EState(SchedUleA). . ... . .. .. . .. .. ... . ... .. .. . .. . . 1. � � � i�������1 ��• r,�
, � Y � ��I �II
2. Stocks and Bonds(SChedule B) . ... .. ... . . .. . .. .. . . . .. . .. . . 2. - � ���,
3. �Closely Held Corporation, Partnership or SolaProprietorship(Schedute C) ... . . 3.
4. Mortgages and Notes Receivable(Schedule D) .. . .. . .. . .. . .. . .. ... . . . .. . . 4. �
5. Cash, Bank Deposits and Miscellaneous Personal Properry(Schadule E). . .. . . . 5. �
� �II
6. Jointly Owned Property(Schedule F) p Separate BUling Requested .. . .. . . 6. ��
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) p Separete Billing Requested.. .. . .. . 7. � '
� 8. 7ota1 Gross AssNs(tofal Lines 1 fhrough 7)... ... ... .. . .. . .. . .. . .. . .. .. . 8.
9. Funeral Expenses and Administrative Costs(Schedule H)... .. . .. . ... .. ... . . 9. „ '
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. ... .. . .. . .. . 10. - , �
�
11. Total DedueNonc(tofal Lines 9 and 10). . .. . . . .. . .. . . . . .. . .. . .. . .. . . . .. . 11.
12. Net Value of Eshte(Line 8 minus Line 11) .. . .. . .. . .. . .. . . . .. . . . . .. .. . . . 12 �.
13. Charitable and Govemme�tal BequestslSec 9113 Trusts tor which
an election to tax has not been made(Schedule J) . .. . .. . . . . . . . . . .. . .. . .. . 13.
14. Net Value SubJact to Tau(Line 12 minus Line 13) . . .. . .. . .. . .. . . . . . . . . . .. 14. '.
TAIf CAICULATION-SEE INSTRUCTIONS FOR APPLICABLE�RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
trensfers under Sec.9116 ����y� �n r� �..
(a)�12)X.0- �.�t�i ..�� 15. �
16. Amount of line 14 taxable , T ��I ��
at lineal rate X A_ : S � � �g.
17. Amount of Line 14 taxable
- at sibling rete X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
19. TAX DUE ... . .. ... ... .. ... .. . ... .. ... ... . .. . .. ... ... ... .. . .. . .. . .. 19.
20. FILL IN THE OYAL IF YOU ARE RE6�lESTN6 A REFUND QF AN OVERPAYYRNT �
Side 2
� 15056b0105 15056b0105 J
REV-7500 EX Psge 3 Fiie Number
Decedent's Camplete Address:
DEGEDENT'S NAME
�-------- ---.-_-----....__.-------------
STREETADDRESS
-----_. . , — ----------
CIN �STATE �21P
i
Tax Payments and Credits:
1. Tax Due(Page 2,61tie f9) {i}
2. GreditslPa}�rents
A.P�ior Payments ___ � ___ _
B.Discount
------ ___ Tnt�Gredits(A+B} {2)
3. Interest
(3)
4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is Ne OVERPAYMENT.
FiN�o+r�on P�e 2,lMe 20 to request a refund. {4)
5. N Line 1 +Line 9 is greater than line 2,enter the di6erence.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 trar�sfer a�: Yes Na
a. retain the use or income of irie property hansterred:.......................................................................................... ❑ ❑
b. retain the right to designate who shail use the praperry translerred or iGS inaome:............................................ ❑ ❑
o. reiain a reversanary interest;oc..................................................._..................._........................................_..... ❑ ❑
d. receive tl�e pranise for 1'rfe of eitber p�yments,taerrefik or care?_.._....,._......_.................._..__...................... ❑ ❑
2. If death occurred after Dec.12,1982,did decedent transfer properry within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ ❑
3. Did decedent am an'in Vust for"a payable-upon-death bank at�u�t or securi(y at hIs or Frer deattr?..........._. ❑ ❑
4. Did decedent own an individual retirement account,ennuiry or other non-probale property,which
contains a beneficiary designation? ........................................................................................................................ � �
IF TNE ANSNtER TO ANY OF THE A88VE QUES't10NS IS YES,Y4U MUST CQIiPIETE SCHEQUtE�AND FlLE tf AS PART pF TNE RENRN�
for dates of death on or after Juty t, 1994,and before Jan.i, 4995,!he tati rate imposed ar tl�e net velue of iransfe�s W w fa the use of d�e surviving spouse is
3 percent{72 P.S.§9418{a}{1.1}(i}J.
Fa dates ot death on or atter Jan. t, 1995, ihe tau rate impossd on the net value of iransfers to or for 1he use of tt�e surviving spouse is p percent
(72 P,S. §91f6{a){t,1){ii)�.The siatute does not sxempt a transfer�a surviving spouse trom tax,and the statutory requirerr+ents for disciasure of assets arx!
fllir�a tax reWm are Sti8 applicat�e euen'rf tl�e surviv�g spouse is the oniy beneficiary.
Far dates of death on or after July 1,2000:
• The tau rate imposed on the net value of transfers from a deceased child 21 yeaes of age or youngar at death to or for the use ot a naturaf parent, an
adoptive pazent or a�epp�ant of the ch�d is 4 percent(72 P.S.§8116(aMf 2)],
• The ta�c rate imposed on the net value of iransfers to or far the use of Me decedenPs lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(1.2)(72 P.S.§9116(a)(1)J.
• Tt�e taa�r�te impased�the net wah�e of hansfers to w for ttre use af tt�e deceder�'s sibiir�gs is 12 per�ent(72 P.S.§9116(a}(1.3}].A sfb�is�fir�ed,ur�r
Secfiott 9142,as an irMividuai who has at least one pareM in common with the decedent,whether by biood or adoption.
aEV-isoz�+{m-io>
"�iypennsylvania SCHEDULE A
�� DEPARTMENTOFqEVENUE
�N„eRnAN�,Ax a�r�RN REAI. ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
All real property owned solely or as a tenant in cpmmon muat be reported at fair market value.fair market value is definetl as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell, both having reasonable knowledge of the relevant faets.
Real pmperty that is jointly-ownad with right of wrrivcrship must be diulosed on Sthedule P.
Attach a copp af tha settlement sheet if the property has been soid.
[TEM Indude a copy of the tleed showing decedent's interest if owned as tenant in mmmnn. VALUE AT DATE
� NUMBER . � pF DEATH
QESCftIPT[ON
1.
�
TOTAL(Also enter on I.ine 1, Retapitulation.) �
if more space is needed,use additionai sheets of paper of the same size,
REV-1503 EX+(6-98}
scN��u�� s
CQA9MCSNWEALTH OF PENNSYLVANIA �`T���' � �N��
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTp7E OF FILE NUNBER
All property�ointly-owned wlih right of survlvorohip muat be dleCloaed on Sabedule F.
�TEM VN.UE AT DATE
NUMBER pESCRlPTION OF 6EATH
1.
TO7AL(Also enter on line 2, Recapitulation) $
{If mwe space is needed,insert additianai st'eets W the same size}
REV4504 EX+(1-97)
scNEOU�E c
� CLOSELY-HELD CORPORATION,
COMMONWEALTH OF PENNSYLVANIA pARTNERSHIP OR
INHERITANCE TAX RETUFN
RESIDENT DECEDENT SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Schedule C-1 or G2(induding all supportin9 information)must be attached for each closely-held corporation/partnership imerest of the decedent,other than a
sole-proprietorship.See instmctions for the supponing information to be submitted for sole-propriebrships.
ITEM NUMBER VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
1.
TOTAL(Also enter on line 3, Recapitulation) $
(If more space is needed,insert additional sheets of the same size)
FEY-1505 EX-r(8-$g}
SCNEEfULE C-1
COh9MONWERLTH 4F PENNSYLVANtA GLOSELY HELD CORPOttATE
I(VHERITANCE TAX RETURN STOCK iNFOkMATION REPORT
RESIDENT DECEDENT
ESTATE OF FILE Nt1MBER
1. Name of Corporation State on Incorporation
Address_, ___ _ __ Dake of Iocarp�sratian
City _ State_Zip Code___ Total Number of Shareholders
2. Federai Empiayer I.D.Number ___, Business RepoAing Year
3. Type of Business�_ __ ProducUService
4. 3TtiC�K `;� �"�� ��' .,� ",'��e
Common $
Preferred $
Provide all rights and restrictione pretaining to each claas of stock.
5. Was the decedent empioyed try the Garporatio�? . ..... . . . ..... . . . . ..... . . ..... . . . ❑Yes ❑Na
if yes, Position i_ ,_ Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to tha decedent? .. . ... . . . ...... . . ..... . . . ..... . . ... ❑Yes ❑No
If yes,prpvide amount of irrdebtedness$
7. Was there liie insurance payable to the corporation upon the death of the decedent? . . . . . ❑Yes ❑ No
if yes,Cash Surrender Value$ � Net praceeds payatrie S
dwner of the policy .
B. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years
if the date of death was prior to 12-31-82?
❑Yes ❑No if yes, ❑Transfer ❑ Sale Number of Shares
Transferee or Purcha&er i__. ___ _ Consideretion$ �Date
Attach a separate sheet for additionai trans#er5 anrUor sates.
9. Was there a written shareholder's agreement in effect at the time of the decedem's death? . ...O Ves ❑ No
If yes, provide a copy of the agreement.
i0.Wasthe decsdenPS stodcsoid? ............................................... ...... ❑Yes ❑No
If yes,provide a copy of the agreement of sale,etc.
N. Was the carporation dissolved or liquidated after ths decedenPs death? .................... ❑Yes � Na
if yes,provkie a breakdrnm of distribuaons received by ttre estate,indu�ing tiates and amo�rrts received.
12.Did the corporetion have an interest in other corporatipns or partnerships? . . . . . . . . . . . . . ❑ Yes ❑ No
If yes, report the necessary information on a separate sheet,including a Schedule C-1 or C-2 for each interesi.
I • • • • � �
A. Detailed ca�ulations used in the valuation of ths decedenYS stock.
B. Complete copies of financiai statements or Federal Corpprate Incame Tax retums{Form 1120)for the year of death and 4 preCeding years.
C. If the corporation owned real estate,submit a list showing the complete address/ea and estimated fair merket value/s.If real estate appraiaels have
been secured,attach copies '
D. List of principai stockholders at the date of death,number pf shares held and their relationship to the decedent.
E. List of officers,their salanes,bonuses and any other benefits received from the c4rporation.
F. Statement of dividends paid each yeac�ist those tfedared and�npaid.
G. Any other iniortnation relaung to the valuation pf the decedenYs stock. �
{it more&pace is nesrkd,insert additionat sheets of the sam9 size) ,
I
REV-1506 EX+(9-Oq)
SCNEbULE C-s
COMM6NWEAlTH 6f PENNSYLVANIA � PARTNERSHIP
INHERITANCE TAX RETURN INFORMATION REPORT
RE3IDENTDECEDENT
ESTA7E 4F FllE NUMBER
t. Name af Partnership _Date Busitwss Commenced
Address 6usiness Reporting Year `
Giq' State Zip Cddo
2. Pederal Emplayer I.D.Plumber T
3. 7ype of Business Product/Service
4. Decedent was a Q C,enera! ❑Limited partnec i#decedent was a IimBad partner,provide ini6al imrestment$
5.
A.
B.
C.
D.
&. Vaiue of the decedeM's interest$
7. Was the Partnership indebted to the decedent? . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No
if}res,provide amount of i�debtetfness$
8. Was there life insurance payable to the partnership upbn ihe deeth of the decedent? . .. . . ❑Yas ❑ No
li yes,Cash Surrender Value$ Net pruceeds payable$� _ _�
Uwner of the poiicy_ --- -,
9. �Did the decedent sell or transfer an interest in this partnership within one year prior to death or within lwo years if the date of death was �
priorto 72-31-82?
❑Yes ❑ Na If yes, Q Transfer �Sais Percentage transferredlsold
Transferee or Purchaser Cp�sideration$ Date
Attach a separate sheet tor additiona!transfers andlor sales.
10.Was thera a written partnership agreement in effeet at tYie time of the decedenYS death? . . .. .. ❑Yes ❑ No
If yes, provide a copy af the agreement.
it. Was ttre decedenYS partnersh�interest soid? ....................................... ❑Yes Q No
If Yes,Provide a�py of the agreeme�rt of sale.etc.
12.Was the psrtnership dissolved or liquidated after the dececlenYs death? . .. . . ... . .. . ... .. . . ❑Yes ❑ No
If yes,pmvMe a breakdbwn of distdbutions receivad by the estate,inctuding dates and artwunts received,
13.Was the dece8ent related ro any of Me pariners? ..... .. . . . . .. . . .. . . .. ......... .. . . .. ❑Yes ❑No
I}yes, explain
� 14.Did the partnership have an interest ir�ofher corporations or partrterships? ....... ....... ❑Yes � No
if yes, repprt the necessary iMOrmetion on a separate sheet,inciuding a Scheduie Pi or G2 for each inte�est.
A. 6etailed cakviatians used i�the vaivation of the decedenYs partnersh�interest �
B. Complete copies of financial statements or Federal Partnership Income Tax retums(Form 1065)for the year of death and 4 praceding years.
G. if fhe partnetship owned reai estate,submit a Nst showirx3 the campiete addressles and�stlmated fair market val�ets.If reai estate appraisals have
bsen secured,attach capiss.
D. My other i�tormation relating to the valuation of the decedanPs partnership interest.
REV-1507 EX+(1-97)
scNEOU�E �
COMMONWEALTHOFPENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX fiETUFN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship muat be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1.
TOTAL(Also enter on line 4, Recapitulation) $
(It more space is needed,insert additional sheets of the same size)
' AEV-isos Ex+(ii-io)
�pennsylvania SCNEp11LE E
oePaRrMerv.oFae�eNUe CASH� BANK DEPOSITS & MISC.
�NHeairnNCe rnx aFruan PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Include the praeeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
IfEM VALUE AT DATE
NUMBER DESCRIPTION Of DEATH
TOTAL(Also enter on Line 5, Recapitulation) ;
If more space is needed,use additional sheetr of paper of the same size.
.. . . ■ �e � � ���
�u�smsx.a�ra �
SCHEDULE F
COMA�MNEAI.TN OF PENNSYIVANiA �VIi'I�1-OWNED PROPER't`Y
INHEPoTANCE TAX RETUftN
RESI NTDECEDENT
ESTATE OF fILE NUMBER
It an aaset was made joiM wlMin one ysar ptthe daeMeM's data of derth,il must 6e reponed on Sehedub 0.
SURUMN6JOIM TENANT(3}NAME ADORESS RELATIONSHIP TO OECEDENT
A.
B.
C.
JOINTLY-OWNED PRQPERTY:
tETTFR DATE ��TqPt4FFROPER7Y %dF 6ATEOFDEATH
ITEM Fp2.iQiNT MAOE ImCWtlenarne0ffit�ci�ins6W60nma1Cankaa0ilMtn�mberWSirtdlmitlen5iyin9nUt�ter.Attach DATEOF6EATH DEG05 VALUEDF
NUMBER TENANT JOINT �(pr'pjpyy-�J igg�ggfg(9, VALUE OF ASSET INTEREST DECEDENT'S INTEREST
i. A.
I
TOTAL,(Also enter an line 6,Recapitulation) S
{If m�e Space is r�eeded,i�xs�k additi�at sheets aF tlie sarrre sire}
REV-1510 EX+ (08-09)
�i�'pennsylvania SCHEDULE G
� oEPnRTMEHTOFnEVenue INTER—VIVOS TRANSFERS AND
'""E"„""`E'^"R�r°R" MISC. NON—PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
This schedule must be completed and fled if the answer to any of questions 1 throuqh 4 on page three of the REV-1500 is yes.
TfEM DESCRIPTION OF PROPERTY
INCWpETHENAMEOFTHEIRANSFEREE,iHE1RREUTIONSHIPTODKEDENiAND DATEOfDEATH %OFDECD�S EXCLUSION TAXABLE
NUMBER iHEDNTEOFTRANSFER. ATTAGIACOWOFTHEDEEDFORREALESrATE. VALUEOFASSET INTEREST (IFAPPLICABIE) VALUE
1.
TOTAL(Also enter on Line 7, Recapitulation) ;
If more space is needed, use additional sheets of paper of the same size.
���
REV-15it EXa(70-pe}
scN�ou�� N
C4MMQNWEALTH QF PENNSYIVANiA FUNERAL EXPENSES & .
iNHEfliTAR10E TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Debta of deaedent must he reported on SchedWe I.
ITEM
NUMBER DESCFiiPTiON AMO�NT
A. FUNERALEXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personai Repressntative's Commisssions . ,
Name of Personal Representative(s)
StreelAddress
City._._ ___ ___ __Siate ZiP _....._...
Year(s)Commission Paid: __
2. Attorney Fees
3. Famiiy Exemption:{If decedenPS address is rrot ihe same as elaimanPs,attaeh exgianatian) �
Claimant
StreetAddress _--
City,__ _ __._ .__ &tate Zip .
Relationship of CVaimant to Decedent
4. Probate Fees
5- AccauntanYs Fees -
B. Tax Return Preparer's Feea
7. `
TOTAL(Also enter on line 9, Recapitulatiqn) $
(It more space is neaded,insert additional sl�sets ot the same size}
REV-t512 EX+{Y2-68) .
�i�'pennsylvania SCHEDULE I
� PEPAftTMENFOfflEVENUE DEBTS OP DECEDENT,
�nnEarrnNCe rnx aErunN MORTGAGE LIABILITIES &LIENS
RESIDENT DECEDENT
ESTATE OF PIIE NUMBER
Report debts incurred by the decedent prtor to death thak remalned u�paid at th�date ot death,Including unrcimbursed medical expenses,
. [TEM VALUE AT DATE
NUMBER DESCRIPTt6N OF DEATH
1.
TOTAL(Also enter on Line S0, Recapitulation) $
- If more space is needed,insert additianai Sheets af fhe same size.
REV-7513 EX+(01-SO)
'�i�pennsylvania SCHEDULE �
j� PEPARTMEN?OFPEYfNUE
�Nnen,TnNCe�nx aEruan BfNEFICIARIES
RESIDENT DECEDENT -
ESTATE OR PILE NUMBER:
RELATIONSHIP 70 DECEDENT AMOUNT OR SHARE
NUMdER NAME AND ADDRESS OF PERSON{S)RECESVING PROPERTY Do Not ust Trustee{sj 4f ESTATE
I TAXABLE DISTRIBt1Ti0N5(Inciude aut+ight Spousal distributiar�s and transfers under
Sec.9116(a}(1.2).]
1.
EN7ER DOLLAR AMOONFS fDR DISTRIBUTIONS SHOWN p60VE ON LINES 15 TNR6UGH 18 QF�REVd500 COVER SHEET,AS APPROPRIATE.
II NON�TA%ABLE p1STAIBUTIONS
A. SPOUSAL DISTRIBUTION5 UNDER SECTION 9113 FpR WHICH AN ELECTION Tp TAX IS NO7 TAKEN:
l.
B. CHARITA9LE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXA6LE DISTRIBUTIONS ON LINE 13 OF REV-1500 CqVER SHEEL $
If more space is needed,use additional sheets of paper af the same size.
REV-,�,&��"2-«�' SCNEdUiE K
LIFE ESTATE, ANNUITY
CO#AMONWEA�TH OF PENNSYtVANiA & TERM CERTAIN
INt+ERITANCE TAX RETURN
RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet
ESTATE OF FILE NUMBER
This schedule is to be used for all single life,joint or successive life estate and term certain calculatfans. For dates of death prior to 5-1-89,
actuarial fectors for eingle life caloulations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factars can be faund in iRS Pubfication 1457,Actuariai Values,Aipha Volume for dates of death from 9-i-$9 to 4-30-99,
and in Ateph Voiume for dates of death from 5-t-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to tbe tax return.
CI Will ❑ Intervivoa Deed of Trust � Qthsr
,
' � �� � ` ' .� �� ,�.
"� r,
❑Life pr O Term of Years
�Life or ❑Term oi Years
0 Life nr O Term pf Years
❑Life ar ❑Term of Years
❑ Life or �Term of Years
1. Value of Cund from which life estate is payeble .... . . . ...... . . . ...... . . . ....... . ....... . .$
2. Actuariai factor per appropriate tabie .. . . . ......... . ....... . . . ....... . . . ..... .. . . ... . .
Interest table rate—O 3 1/2% ❑6% ❑ 10% ❑ Variable Rafe %
3. Yalue of IKe estate(i.ine t multipiled by Lirre 2) . . ........ . . ........ . ........ . . .......$
� �� x � �m «a �>� a . � �. # ..rr
4.L 1 NA 4 A � �ky �nN �14 �q 3 ssk#RGP 4� .µwh � fq.
� 0.bdU tid pkf" "� pittiekk t� p�si
❑ Life or ❑Term of Years
O L'rfe or �Term of Yea�s
❑ Life or ❑Term pt Years
Q L'rfe or �Term of Years
1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Cbeck appropriate biock beiow and enter carresponding{numberj . ....... . . ......... . ......
Frequency of payout—❑ Weekiy{52} ❑ Bi-weekiy(26) ❑ Monthly(12)
❑ Quarterly(4) ❑ Semi-annually(2) ❑ Annually(1) ❑ Other( )
3. Amount of payaut per period ... . . ...... .. ....... . . . ........ . ........ . . ....... . ......S
4. Aggregate annual peyment,Line 2 multiplied by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Annuity Factor(sea instructions)
Intersst tab�e re#e—Q 3 112°l O 6/o a 10°l ❑Variabie Rate °fa
6, Adjustmenk Factor(see instructians) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . .
7. Yalue of annWty— !f using 31/2°fo, 6%, 10°�,or if varlable rats and psriod
payout is at end af periad,caicutetion Is:Line 4 x line 5 x tine B . . . ....... . . . ....... ......�w
If using variable rate and period payout is at beginning pf period, oalculation is:
(Line 4 x Llne 5 x Line 6)+Lioe 3 .. . . . . . ....... . . . ...... . . . ..... . . . .... ... . ....... .$
NOTE:The vaiues of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax reiurn.The resulting lite or annuity interest(s)should be reported at the appropriate tax rate on Lines 13 and i5 through 1&.
{It rtrore space is needed,insert additlonai sheeis of Me same size} ,
I
REV�1644EX+(3-04) 1NFIERtTANCE TAX
scN�ou�� �.
COMM�HERTANCETA%fiETURNAN�A REMRINDER PREPAYMENT
RESIDENT DECEDENT OR #NVASION OF TRUST PRENCIPAL fl�E NUMBER •
I. ESTATE OF
(�sst r�ame) {F«st r�arne} {r�ue in��ary
This schedule is appropriate only for eatates of decedenta dying on or before Dscamber 12, 1962.
This schedule is ro be used for all remainder returns when a�election to prepay has baen filed under the provisions of
SecBan 714 of the Inheritaince and Estafe Tax Act of 1861 or to report the invasian of trust pri�apai.
II. REMAINDER PREPAYMENT:
A. Election ta prepay fited with the Register of Wilis on
(Date?
B. Name(s)of Lifa Tenant(s) Date of Birth Age on date Term of years inwme
or Annukant(s) of eiedipn or annuity is peyable
C. Assets:Gompiete Schedute�-1
1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Stocks and Bonds . . . .. . . . .. . . . . .. . . . . . . .. . .5
3. Closeiy Heid StocktPartnership . . . . . . . . . . . . . . .$
4. Mortgages and Notes . .. .. . . . .. . . . . . . . .. . .. .$
5. CashlMisc. Personai Properfy . . . . . . .. . . .. . .. .$
6. Tatal from Schedule L•1 . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$
6. Gredits:Campiete Sd�edule l-2
1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Unpaid 8equests. . . . . . . . .. . . . . . .. . . . . .. . . . .$
3. Vs�ue of Unincludabte Assets . . . . . . . . . . . . . . . . .$
4. Total from 5ahedule L-2 . . .. . . .. . . . .. . . . .. .. .. . . . . .. . .. . . . . . . . . . . . . . : . . . . . . . ..$
E. Totai Vaiue of trust assets(Line C-6 minus line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$
F. Remainder factor(see Table I or Table 1! in Instruction Booklet} . . . .. . . . . . . . . . . . . . . . . . . ..
G. Taxable RemairMer value{line E x line F) . . . .. . .. . . . . . . . . . . . . . . .. . . ... .. . .. . . ... ..$ _
(Also enter on Line 7, Recapitulation)
III. INVASKlN 8F GORPk7S:
A. Invasion of corpus
(Month, Day,Year)
( B. Name(s)of Lite ienant(s} Date of Birth Age on deke Term of years income
, or AnnuitaM(s) corpus or annuiry is payable
consumed
C. Corpus consumed . . . . . . . . .. . . . . .. . .. . . . ... . .. . .. . .. . . . . . . . .. .. . . . . . . . . . . . . . . .$
0. Remainder tactar{see 7able I or Ta4ie tt in instruction Baok{et} . . . . . . . . . . . . . . . . .. . . . . . . .
E. Taxable value of corpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
(Aiso e�ter on�ine 7, Recapitnlation)
I �
PEV.,rw ex+ pas�
INHERITANCE TAX
SCHfDULE l-7
COMMONWEAtTH Of PENNSYIVANiA �EMAINDER PREPAYMENT ELECTION
INMERITANCE TAX REIURN
RESIDENT pECEDEN7 -ASSETS- FILE NUMBER
1. Estate of
�Latt Nami) � �fint Nam�� (MiddM IniBan
!I. lt�m No. D+ruri tion Volut
A. Rsat Estats (plaase deacribsj
TWaI valua oF rsal s;tats $
indude on Sedion II, Lina C•1 on Schsdule L
9. 5tacks and Bonds (piwss iist}
Totat valw�stocks r�nd bondt $
indude on Ssction 11, line C•2 on Schadub 1)
C. Clo»ly Hdd St«k/Porrn�nhip (aMacA Sch�duls Gl and/or C-2a
(plaass lisi}
Total value of Clo:�ly Hsld/portn�rahip S
includs on Section II, Lins C•3 on Schedub L�
d. Mortgapes c�d Notes{plaase Iist}
(
�
Total valua oF Mortgag�s and Not�s 5
nduds on Saction {i:Line CJ an Sdroduter
E. Cash and Misc�Ilaneour P�nona) Proparty (pisasa listi
Total valua of CashlMisc. P�rs. Prop�rty S
_ induds on S�ctioa U, Line C5 on Schsdule Lj
�«• TOTA{, Also an»r on S�etion 11, Lini C-6 on 5thsdula L $
(If moro spacs is owded, attach additional 814 x 11 sh��s.�
��
aev-ieeaex� {aee� ��HERITANCE TAX
� SCHEDULE 1-2
cor,v+oNwea�rH aF PeNNSr�vnNiA (�EMAINDER PREPAYMENT EEECTIi�N
INHERITANCE tAX RETURN
RESIDENT DECEDENT -CREDITS- FILE NUM9ER
I. Estate sf
(Last Name) (Firxt Nama) (Mid(��e Initiol)
II. Item No. Description Amount
A. Unpoid I.iabilities Clvimed againet Qriginal Estbte, and payabls from assets
reportad on Schedule L-1 (please list)
Totat unpaid Iiabilitiss $
(include on $ecfion II, Line D•1 on Schedule L)
B. Unpaid 6eqvests payabie from ossets reporled on Schedule L-t {please (iet)
Total unpaid bequests $
(indvde on Section it, line p-2 on Sthedule L)
C. Volue of assets reported on Schedule L-1 (Whar than unpaid bequssts listecf under
"B" above) that are not included for Tax purposea or that do not form a part
of tha truat.
Computation as follows:
I
Toial unincludable assets $
(include an Sedion II, Line D�3 on Schadule L
III. TGTAC Also antat on Sectian iI, i.ine D-d on Schedale t $
(If more space is needed, aBach additional 8'h x 11 sheets.)
aev-isa�ex+ �oz-io�
�`pennsylvania SCHEDULE M
oEPna,„fNT oF AEUE„�E FUTURE INTEREST COMPRQMISE
INHFRITANCETAXRE7URN
RESIDENT DECEDENT (Check Box qa on REV-i5oo)
ESTATE OF FILE NUMB£R
This schedule is appropriate only for eskates of decedents who died after Dec, i2, 1982,
This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in
posszssion and enjoyment cannot be established with certainty.
Indicate below the type of inskroment that created the future inkerest and attach a cnpy to the tax return,
❑ Will ❑ Trust � Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP pATE OF BIRTH AGE TO
NEAREST BIRTHDAY
i.
2.
3.
4.
5.
II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exerdse a right of withdrawal within
nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse
exerdses suth withdrawai right.
� Untimited right of withdrewa! ❑ Limited right of withdrawai
III, Explanation of Compromise Offer:
IY. Summary af tompromise 4ffer:
i. Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
2. Value of Line 1 exempt from tax as amount passing to charities, etc,
{Also indude as park of tatai shown on Line 13 of REV-iSQO.} . . . . . . , . $
3. Value of Line 1 passing to spouse at appropriate tax rate
Check one. ❑ 6°/a, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . $
(Also include as part of totat shown on Line 15 of REV-1504.}
. 4. VaVue of Line i taxable atiinea! rate
Check one. ❑ 6°/a, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $
_ (Also indude as part of total shown on Line 16 of REV-1500.)
5. Value of�ine 1 taxable at sibting rate{12°fo)
(Also indude as part o(tptal shown on Line 17 pf REV-1500.} . . . . . . . . $
6. Value of Line i. taxable at collateral rate(15°/a}
(Aisa indude as part of totai sMawn or� Line i8 af REV-1506:} . . . . . , , . $
7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . $
If mflre spate is needed, use additionai sheets of paper of the same size. '
i
REV-1649 EX+(OB-09)
�pennsylvania SCIIEpYLE O
DEPAPTMENT OF PEVENUE
MHERIIANCE TAXES REfURN ELECIION UNDEH SEC.2113(A)
RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS)
ESTATE OP FILE NUMBER
Do not complete this schedule unless the estate is making the election to tax assets under Section 2113(A) of the Inheritance and
Estate Tax Act.
If the election to more than one trust or similar arrangement,a separate form must be fled for each trust.
This election applies to the Trust(marital, residual A, B,by-pass,Unified Credit,etc.).
If a trust or similar arrangement meetr the requirementr of Section 2113(A)and:
. a.The trust or similar artangement is listed on Schedule 0 and
b.The value of the trust or similar arrangement is entered in whole or in paR as an asset on Schedule 0,then the tronsferor's personal representa-
� tive may specifically identify the trust(all or a frac[ional portion or percentage)to be included in the eleQion to have such trust or similar proper
ty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on
Schedule 0,the personal representative shall be considered to have made the elec[ion only as to a f2ction of the trust or similar arrangement.
The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0.The denomi-
nator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the
decedent's surviving spouse under a Section 2113(A) trust or similar arrangement.
Description Value
Part A Total $
PART B: Enter the description and value of all interests included i� Part A for which the Section 2113(A) election to tax is
being made.
Descrip[ion Value
Part B Total $
If more space is needed,use additional sheetr of paper of the same size.