HomeMy WebLinkAbout10-10-13 (2) " s �
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= Y`' �� 1505610101
REV-1500 °`�O1_1O, '�
OFFICIAL USE ONLY
PA Department of Revenue pennsytvarria Coun Code Year File Number
Bureau of Individual Taxes �v�TMENTOFPEVENUE �
PO BOx z8o6o1 INHERITANCE TAX RETURN
Hamsburq,PA i��&o601 RESIDENT DECEDENT /2 � � 3 � O t 1
ENTER DECEDENT INFORMATION BELOW
1 � 2 I 2 0 � ° � � �����, ������
Z.IZ� z � � �
Decedent's Last Name Suffix DecedenYs First Name MI
� o � �lE K � � N �ETH �
(If Applicabie)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
T� o o �e 1< /� T �# fc R r N � �
Spouse's Social Secxirity Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
� $ � � �° � ? � 9 REGISTER OF WILLS
FILL iN APPROPRIATE OVALS BELOW
� 1.Original Retum p 2.Supplemental Return Q 3. Remainder Retum(date of death
prior to 12-13=82)
p 4.Limited Estate p 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Retum Required
death after 12-12-82)
� 6.Decedent Died Testate p 7.Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
Q 9.Litigation Proceeds Received Q 10.Spousal Poverty Credit(date of death p 11. Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULQ,�E DIRECTED T0:
Name Dayti�Telephone�nber, �3'
CI� Et� YL L t3 (� TNk R � `� �_ 2 �Z
�t T8 �F�,VI�LL8�,tl�� LY
�y",,_ �= �C p .°� t�
. .J�+"° Y�+e .s„`�`y'd �P�. :.
-.�,p. s.i♦
First line of address ��~ � �
� � 4�� � � �
y t o L a N � V l� L � S Y R E � �' � �.: �`" .,� �,
Second line of address " '"� ~ ��� �i`��
� --� t.�...
� L,� fj�� C'�
C�
City or POSt Office State ZIP Code DATE FILED
ii■ r. iiniii� iin■ nin■ � nniiiiii iiiiiiii. �iid
rl � R Y s v 1 � t E P A rj��10���3�� �z' �171
Correspondent's e-mail address:
Under pena�ies of peryury,I dedar�e that I have examined this retum,inGuding accompanying schedules and statements,and to the best of my knowledge and belief,
it is trve,cbrrect and complete.Declaration of preparer other than the personal representative is based on all infoRnation of which preparer has any knowledge.
SIGN RE OF PERSON ESPONSBLE OR FILING RETURN DATE
. . q zo 13
ADDRESS
�� d � a»SVA � � Sfrcc �
I�Ic�rySv� �� t , Pa• �]�0�3
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
- Side 1
� 1505610101 1505610101
�
.
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� 1,50561,01,05 � �
REV-1500 EX DecedenYs Social Security Number
DecedenYs Narne: � � � � `� " � � � �
RECAPITULATION
1. Real Estate(Schedule A). .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 1. � . O O
2. Stocks and Bonds(Schedule B) . . . . . .. . . . .. . . . . . . . . .. . . . . . . . . . . . .. . . . . 2. � � y � ` * � �'l
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. .. 3. � • � O
4. Mort a es and Notes Receivable Schedule D 4� � ' � �
9 9 ( ) . . . . . . . . . . . . . . . . . . .. . . . .. . .
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. { 1 �3 `'� ( • `"� �
6. Jointly Owned Property(Schedule F) p Separate Billing Requested . . . . . . . 6. ` � . O O
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested.. . . . . . . 7. � *� 8
8. Totai Gross Assets(total Lines 1 throu h 7 $• ' 1 (.� 1 $ ' Z � * � �
9 ). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . . . . . . . 9. 7 `3 � � . 5 '�
10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . . 10. � D R + L{ j ;
11. Total Deductions(total Lines 9 and 1Q). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 1 y � � s � ��
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. � g �, 3 'z. ,� • y j�
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. d « � �
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. [ '� Z, �� � 3 • �{ �.
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amaunt of Line 14 tax�ble
at the spousa�tax rate, or
transfers under Sec.9116 '
�a)�1.2)X.0- �``� L{ � Z( . (o �j , 15. Q � d O
16. Amount of Line 14 taxable c� ° � ..
at lineal rate x.o- � `� . � C� � � '. -T c�` 16. , �p � � 3 . � � '
17. Amount of Line 14 taxable
at sibling rate X.12 . *� 17• ' '
18. Amount of Line 14 taxable
at collateral rate X.15 • �$• ' 6 ' � ��
19. TAXDUE . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . 19. , Us � �
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� Z5056101,05 15056101,�5 �
. ,
REV 1500 EX Page 3 File Number �� � 3 �O�1 1
Decedent's Complete Address:
DECEDENTS NAME
k � nntt� �, C . ioo�► �
STREET ADDRESS �q� �
�ZZ� WI � 58�1 �-c�� G �(� �• � �� �
��N STAT ZIP
�{ e t1n�� � � s b � r �en��• I?o�S
Tax Payments and Credits: �
1. Ta�c Due(Page 2,Line 19) (1) Zo� b �3• `'y
2. Credits/Payments
A.Prior Payments
B.Disoount
Totai Credits(A+B) (2)
3. Intere.st
, . �3� �
4. Ifi Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT.
Fiit in aval on Page 2,Line ZO to reqt�est a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) �lv , `S 3. ` �
Make check payable to: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIQNS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain�e use or income of the propert�r transferred:.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ �
c. retain a reversionary interest;or.......................................................................................................................... ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If deatl�occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate c:onsiderafion?.............................................................................................................. ❑ �
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 acxount,annuity or other non-probate property,which
contains a benefiaary designation? ........................................................................................................................ ❑ �
IF THE AN�R TO�INY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART�THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the sunrivving spcwse is
3 percent[72 P.S.§9116(a)(t.1)(i)].
For dates of death an or after Jan. 1, 1995, the tax rate imposed on the net valuE of Vansfers to or for the use of the sunriving spouse is 0 percent
[72 P.S.§9116{a),(1.1)(u)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requiremer�ts for disdosure a#�ss�ts ar�!
`f�ling a tayc retum ar�e still appiicable even if the surviving spouse is the only benefiaary.
For dates of death on or after July 1,ZOQO: �
. The tax rate imposed on fhe net vawe of transfers from a dece�ased child 21 years of age or younger at death to or for the use of a �ahira{ p�anent, an
ac�tive panent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed an the net value of transfers to or for the use of the decedenYs lineal benefrciaries is 4.5 percent, except as noted in
72 P.S.§9116(1.2}(72 P.S.§9116(a}(1)].
• The ta�t rate imposed on the r�et value of transfers to or for the use of the dec�dent's siblings is 12 percent[72 P.S.§9116(a)(1:���.A sibling is defined,under
Section 9102�as an ir�tividual who has at least one parent in common w'rth the decedent,whether by blood or adoption.
_
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REV-1503 EX+(6-98)
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SCNEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kc r►r►�.�-In C , %oo•� t Y �o t3 oas 1 �
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. � W 5 �r�v t s�'m t,r�} s ( 1'1 t1�'�a� �"�✓�c� s ) � 2 0� 21 8 • 5�(
�, I�t�veen �.lr^vts �'m��� s � I''1v �'va � rvn d s ) silo���.t17• S5
3• c�rd � b�o� �' 1''lv� ua � �v»c� s � �(, Ll `� l . � �
� � �
Irabe � Uivi dc,r. � C�1cc�� ��.�z8�1 z� � x 5• 1�$
t-�� �p r d � �
�
' " � C�'1ec.�c 3 ��$� 13) Zz. 18
,�'. �..o , d ►� bb� t� C D� �,d ��,
es G� Z1�� 38103$ �i23 01-! t� 9 �
� . 1! eri son � 5�-ocic � � (v $ shaY )
C V �i P � �.3 � � V 1 � � Co m�'►'►o� S f'a c�G.
ror��"� eY uni c��� o� s � S�'ock � �
�, � �orY�m �3 � • � 3
11 �. 5hc��eS � ��• � 3oaql�S�t�c.r �
� US ! � �� � � �v � 1�8 �or»,�r�on ��"o c�
TOTAL(Also enter on line 2, Recapitulation) $ q p �( $ �. O�{
(If more space is needed,insert additional sheets of the same size)
+ REV-1508 EX+(11-io)
� � pennsylvania SCI�IEDVLE E �
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERnANCE T,vc RErURN PERSONAL PROPERTY
RESIDENT DEC�EDENT
ESTATE OF: , . FILE NUMBER:
�Ccr)rt � �'�1 C . TpomeY Zo 1 3 Da.�ll
Include the proceeds 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.
ITEM VALUE AT DATE
NUMBER DESCRIPTION � OF DEATH
..-.
�. t'' tY 5 � Nct,-� . �an�f o � �QYySVi ��G �C � �dl�x �$ i , 7 ��2.�j� � $(o
,�- � �� t �arys� ���� C � � �a� ss � g� �.lo OOD� OZ�
�• " �i f s �A�, a+n Q 1
�
, ' . 'I�a,n�� o � 4Y s�� 1�� (�� 30�� � 2os� l 5� 000.av
3 �, Y �r Nat � y
� e c� 30� zSz7� �33 os�. 3 q
ar►,c. b � r l a r g V 1 1�� � �
�{ � � � rs�' J�Q� � � Y
,, vi 11� C� o �o� z85'�� � Io, 000, oc�
�`, � ;� S t� 1,��.�. �ank � � �a y 5
� �� �, CC I� 3D� � OSS� ��I � OD'3. I �
10 � r s�" Q� �Q�1� d� 1�QY1(s v 1 �
�� �
TOTAL(Also enter on Line 5, Recapitulation) $ Q Q 3 1{1, �{�
If more space is needed,use additional sheets of paper of the same size.
' REV�-1511 EX+(10-06)
• � SCNEDULE N �
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECED�NT �
ESTATE OF � FILE NUMBER
� K � n ►� �. +-h c , Too,��y 20 � 3 aos � t .
" Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. �
��� b Y��S �U�1 e Y a � �o YY1 e+ �
b��z a .�'7
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions �
� Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid:
2. Attomey Fees �
3• Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation) �
Claimant •
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees � ��3. ��
5. AccountanYs Fees
6. Tax Return Preparer's Fees f
7 L L �oj"j C � � ��• ��
. �� ST �ii�� �
g� R� C� � tmOY'1c� � �� ri+5 t Gra�c. SI �n� ! #� lo� . 00
' � 1"�c�i � � � 18. �l
q• ve,r � s o�n � l�Ze�► ��'e,r t c�
}�. � L ��1�►� 1 � � � . t�
'a` �..,.Cr� �bbe11 t � t`�1STe�fe d �
TOTAL(Also enter on line 9,Recapitulation) $ � 3 $q� J��j
(If more space is needed,insert additional sheets of the same size)
s � � •
REV-1512 EX+(12-08)
' ' SCHEDULE I
� pennsylvania .
DEPARTMENT OF REVENUE DEBTS OF DECEDENT�
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
k � � �,� �� � � �roa .� � y �o � 3 o�.� i1
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
�. Caei �a � . � �ec�, �'¢a� �h R�Sa�� �+�s � 1 p y
t. �
- TOTAL(Also enter on Line 10, Recapitulation) $ � 0 Q• �{�
If more space is needed,insert additional sheets of the same size.
. . . .,
REV-151�EX+(01-10)
. �
� pennsylvania SC H E DU LE �
DEPARTMENT OF REVENUE
INHERITANCETAX RETURN BENEFICIARIES
RESID�NT DECEDENT
� ESTATE OF; � � � C � D� �t� FILE NUMBER:
� '�' 'r'� ' � 2.0 13 0 0 �"I,!
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
�. �� a ���Y � �,t:. � . roo�� �
W, �� �u� � `y . � S
� 2z S (�i 1 �0�'► l-a� � ��'. �r1 �O
1``��. cl� a��� � s b � Y � {�'a. I�loS�
�
�� ���Y � L . � �'1 ✓1e� av ���.�f $ 58. ��
y � � 1 '-l�t, 8
� 1 a �..a �n � vQ� L Str ct �' .
�`�ar sUil � t �� • 170�3
� �.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR,WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
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.