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Home My WebLink About12-02-13 (2) 1505610101 REV-1500 Ex °'"°' ' Pennsylvania ` • - OFFICIAL USE ONLY PA Department of Revenue P Bureau of Individual Taxes Code Year File Nu r PO BOX28o6o1 INHERITANCE TAX RETURN �� 1�i' Harrisburg PA 17128-o6o1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW lldw 0 Decedent's Last Name Suffix Decedent's First Name MI ® E TV (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ^J O 1.Original Return O 2.Supplemental Return O 3. Remainder Return(date of death . ' 1. A : . . prior to 12-13-82) O 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required 1 death after 12-12-82) ® 6.Decedent Died Tasters O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number REGISTEPK F WILLS US4��LY OD -zj m - � First line of address no 17 r-� c-:, no S eb n CD rri Second line of address O - 7c a C(n pC'� City or Post Once State ZIP Code SATE FILED.— •� Z t� — R IVU e I Z o 0 C.0 Cr) W Correspondent's a-mail address: Under penalties of perjury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief, it is We,correct and complete.Declaration of preparer other than the personal representative is based on all information of which prepaer has any knoveledge. SIGNATURE OF f ERSt71CIRESPONSIBLE FOR FILIN R TURN DATE � 2- ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE — DATE ��DS —/-3r ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 � 1505610105 REV-1500 EX DecedenYs Social Security Number ��, � ., DecedenYs Name: , � �� / RECAPITULATION -..� _x�r'Y.,,e,�L. "°a��rs-A�d...� fi+h'.� T�"'w r�.vS2� 1. Real Estate(Schedule A). . .. .. . . ... .. . .. .. .. .... .. .... ... .... .. .. .. .. 1. � � � y . �a<;� �� :,.��,� ��"��.�� _.:�� ,'` � � � �� 2. Stocks and Bonds(Schedule B) ... .. .. . .. .. .. ...... .. .. .. ..... .. .. .. .. 2 ' � � � � � ,;��_�� % � � � � �� 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. ... 3 �f � t � � �� ";,k°�'+w� �4;a��'��"�`",�, "�� m = , <� � g � � _ � � � 4. Mortgages and Notes Receivable(Schedule D).. . ... .. . . .. .. . . . ...... .... 4 r � � �' , � :�'��F "`� 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. ... 5 �a , • o~ �. �; � �� 6. Jointly Owned Property(Schedule F) p Separate Billing Requested .. .... . 6 � � a � � � � � � �� .,u � � � �� 7. .Inter-Vivos Transfers&Miscellaneous Non-Probate Property �' F ; � � �° (Schedule G) p Separate Billing Requested... . .. . . 7 ;� � � � � � � � � � � �� 3��,,�`��' �� .��+,�� 8. Total Gross Assets(total Lines 1 through 7). . .. .. .. . . .. .. .. . . . . . .. .. . . .. 8. � � � _ � . ..o � � 9. Funeral Expenses and Administrative Costs(Schedule H). . . . .. . . . . . .. .. .. . . 9 � � � �� ` � �/� /� ��j 7 /"�}�� . ��;�;�� .�, i9 V� �/;u� �,.�"" 10. Debts of Decedent, Mort a e Liabilities,and Liens Schedule I 10. � _ � � � � �� 9 9 � ) . . . .. . . . . . . . . . . � �w�a �,s�„;�a ,� �- �.��=�„r ��: � n � �t �� r = � : . .. . . . . . . 11. ,� r � � � � � � � 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . .. .. . . . .. . � � �� `��a �� :� u„ .�' ,k� � 3# e. ` 12. Net Value of Estate(Line 8 minus Line 11) . . . .. . . . . . . . . . . . . . . . .. .. . . . . . . 12 � � ; ' � � , , �� . � � � �� 1,3. Charitable and Govemmental Bequests/Sec 9113 Trusts for which � �� y ° _ ' �.=' an election to tax has not been made(Schedule J) �. . . . . . . . . . . . . . .. . . . . . . . . 13 � � � � � �' Q� 0 � � . ' ' .rw �„� . . �.. �� .. � a , .,� �� 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . .. . . . . .. . . 14 � � �° � r �..�_R � y,-� ��.. �...r_�r TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES � 15. Amount of Line 14 taxable i � at the spousal tax rate,or � transfers under Sec:9116 � � , , � �'� � °�; '°^� � ��"�"��' � ��"`�'��°°� � �� '� �a)�1.2)X.0- � � � � � � � �� 15. � � � � :�r�� u� �� 16. Amount of Line 14 taxa e � � �`�� _ �''„, � �� ' � �` at lineal rate X.0�� 16. ' � �� „ �� _ � � = x� �� ,n�=� ��r �x'��"' ° � 17. Amount of Line 14 taxable � � `�� at sibling rate X.12, � � � �� 17. - 18. Amount of Line 14 taxable � � � �' �� `' �� at collateral rate X.15 � � � � � � � � 18. � �� ; ..� a��:r��..�, ` " �' � � a��:"�` 19. TAX DUE . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. .. . . . . . . . .. . . . . . . . .. 19. �' �� ; . ��' � ��f�'a 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610105 1505610105 � REV-1511 EX+(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: h1r�r(s Bur-� g75.�C7 n 15`per-pe, 5�-s B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip _ Years)Commission Paid: 2. Attorney Fees 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 16- c v 6. Tax Return Preparer's Fees 7. TOTAL(Also enter on line 9, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1508E%�n9n SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of lifigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. 19 Y, 60 CkcC� ' TOTAL(Also enter on line 5,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER 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.2116(a)(1.2).1 i. 383/ 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 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS +1dh '� TSS / I� °l � ' C_ 1 _ p o S T d911 IJ VIC e_ W\ ecl\bv% CS�u� Po I a 5A3;15 r(, �' I yg57 . U6r f-en e A(-it` v (J F E SC-J ve Jj1 e oWA 049 , )719 5 TOTAL OF PART U—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET. $ 2 Qa 0 If more more space is needed,insert additional sheets of the same size. REV-1500 E`! Page 3 File Number Decedent's Complete Address: DEC ENT'S NA r . STRET DDR M �//�SSSIII' __•111` III 111 E AE S > IoLo 6�c_ r �V c CITY STATE 40 A ZIP Tax Payments and Credits: _ 1. Tax Due(Page 2,Line 19) (1) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 3. Interest 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.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 transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... ❑ l� 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?...................................................................... ❑ p< 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ [� 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 account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF 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 surviving spouse is 3 percent[72 P.S. §9116(a)(1.1)(1)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(x)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent p2 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.