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Home My WebLink About11-27-13 � j � , 150561�101 REV-1500 °`�°i_i°, �' PA Department of Revenue P�n��a OFFICIAL USE ONLY Bureau of Individual Taxes ��TMENTOFREVENUE County Code Year File Number Po BOx 28osoi INHERITANCE TAX RETURN Harrisbu �PA 1�s28-o601 RESIDENT DECEDENT � ENTER DECEDENT INFORNtATION BELOW Sociai Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY [ �' � � [oTz1'z 3 , 3 �- -�,�� .�� 9� Decedent's Last Name Suffix DecedenYs First Name MI � (tf�►pplicable)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 � 1.Original Retum p 2.Supplemental Retum Q 3. Remainder Retum(date of death prior to 12-13-82) Q 4.Limited Estate Q 4a.Future Interest Compromise(date of p 5. Federai Estate Tax Retum Required death after 12-12-82) Q 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) p 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) betwe�n 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone ber � � ..r S�R O : LY � � � � � � � � First line of address :;� � � p C„� �7 � � ;� � 'Y'� 7 � � � � � Second line of address � � N �„�"'"._ � � � � � City or Post Office State ZIP Code DA�FI�D �� .� ��. �..� ..�� . � � r��or��-rT-n . _. co��onaent's e-mail address: Under penal�es of pery'ury,I declare that I have examined this retum,induding accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE F PER RESPONSIBLE FOR FILING RETURN : DATE .��Z- DRESS ^ =� /T .�7_" /N�f �. SIGNATURE OF PREPARER OTHER TH REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610101 1505610101 J W � �505610105 REV-1500 EX Decedent's Social Security Number DecedenYs Name: � / � � � �� RECAPITULATION 1. Reai Estate(Schedule A). . . . . . . . .. . .. . .. . . .. . . . . . . . . . .. .. . . . . . . . . ... . 1. 'v ' !/ v 2. Stocks and Bonds(Schedule B) .. . . ..... . .. . . .. . . .. . . .. . .. . . . . . . . . . . .. 2. ' �/' Y/� 3. Closely Held Corporation, Partnership or Sole-Proprietorship(5chedule C) . .. .. 3. � • ��'' 4. Mortgages and Notes Receivable(Schedu{e D) . . .. . . . . . . . . . .. . . . . . . . .. . . . 4. �• �� 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E}. . . . . . . 5. ' 3 �5 5• �7, 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . . . . . . . 6. � •�Q` 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested.. .. . . .. 7. � •�,O' 8. Total Gross Assets(total Lines 1 through 7). .. . . .. . . .. . .. . . . . . .. . . . . . . . . 8. � 5� �. � ,' 9. Funeral Expenses and Administrative Costs(Schedule H). . . . .. . . . . . . . ... . . . 9. '� 6�,p` r�3 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) .. . . . . . .. . . .. . 10. ' � �.d � . 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 11. � �f 6 3 p' S'`3: 12. Net Value of Estate(Line 8 minus Line 11) . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 12. �. a�. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. . . . . . . . . . .. . . . . . . .. . . . 13. ' �+,� � 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. ' b•;�O TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ : . 15. s 16. Amount of Line 14 taxable at lineal rate X A_ . 16. ., 17. Amount of Line 14 taxable at sibling rate X.12 . 17. �'' 18. Amount of Line 14 taxable at collateral rate X.15 • 18. � 19. TAX DUE . . . . . .. . . . . . . .. . . ... . . .. . . ... . .. ... . . .. . . .. . . .. . . . . . .. . . . 19. ' o�►�.:� 20. FILL IN THE OVAL IF YOU ARE REQUESTlNG A REFUND OF AN OVERPAYMENT p Side 2 � 1,50561,01,05 150561,0105 � . • REV 1500 EX Page 3 Fife Number Decedent's Complete Address: DECEDENTS l�fAME STREETADDRESS � CITY STATE ZIP � Tax Payments and Credi#s: 1. Tax Due(Page 2,L'me 19) {1) 2. CreditslPaytr�er�ts A Prior Payn�enfis B.Discoun# Tota1 Credits(A+B) (2) 3. Interest � (3) 4. !f Ur�e 2 is�eater tiran Line 1}Une 3,enter the differerx:e. This�s U�e OVERPAYMENT. F'i!t in oval on Page Z,Line ZO to requ�t a re#und. (4) 5. If Line 1+Line 3 is grsa#er than Line 2,enter the diFference.This is the TAX DUE. (5) Make check payable to: REG�STER OF WlLLS,AGE�1T. PLEASE AMSWER THE FOL�OIIVING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. r�tain the use or inc�me o#the property transfemed:......................................................................................... ❑ (� - b. retain tl�e right to designate who shall use the propert�r transferred or its income:............................................ ❑ c. netain a reversionary inter8s�or.......................................................................................................................... ❑ d. receive the prom+se for life of either paymen#s,benefits w care?...................................:.................................. ❑ � 2. If death occ�med ai�er Dec.12,1982,d�decedent transfer property within one year of death H►ithout receiving a�eqtrate consic�ration?.............................................................................................................. ❑ � 3. �d decedent ovm an"in Vust for"or payable-upon-death bank accourrt or security at his or her death?.............. ❑ � 4. Did decedent oxrn ar�individual r�tirement account,annuity or o#her non-probate property,which oon#ains a benefiaary des�,�nation? ........................................................................................................................ ❑ � IF THE AWS?IN��O ANY OF T�E ABOVE+f�lEST14NS iS YES,YOU MtiST C4�lPLETE SCHEDULE G AND FILE 1T AS PART OF THE RETURN. For da#es of de�ath on or ai�July 1,1994,and before Jan.1,1995,#he#�x rate impased on tt�e net value of transfers to or for the use of the surviving spcwse is 3 percent[72 P.S.§9118(a)t1.1)(i)]. Foc dates of dea#h on or after Jan. 1; 199�, the tax rate im�sed on the ne# vaiue ofi trans�ers �o or for the use of the surviving spouse is 0 peroent (72 P.�.§9'116(aj t1•�)(�)j,The stah�tee�es no#�acempt a transfer to a survivmg spouse from tax,anti the statutaY re�uiremen#s fa�dis�OSUre of assets ar� f�mg a tax r�xn a�e�st�applicab��en if the s�urviving s�xwse is the oniy benefiaary. For date.s of d�#h or�or a�er.h�y 9,2000: . The tax ra�e�posed on#he r�t va�e a�trans#ers from a deceased chiki 21 years o#age or Ycwnger a#death to or for the use of a natural parent, an �P�P�a'a s�epparen#of tl�d�d'as 0 percen#[72 P.S.§9116{a){1.2)]. • The tax rate � on the ne# waiue of trans#ers to or #a� t�e use of the deoedent's lineal benefiaar�s is 4.5 percent, except as noted in 72 P.S.§9116{9.2)�72 P,S.§991fi(aK1)J. . The tax rate imp�ed on t#�e r�t va�ue o##rar�s tv a for the use of the decedent's siblings is 12 percent(l2 P.S.§9116(a)(1.3)�.A sibiigg is defir�ed,under Sec�ion 9142,as�ir�ividua�wtro has at least cme par�ent in comrnon with the dec�ent,wtiether by blood ar�option. � REV:tgo8 EX+(ss-so) � enns lvania SCI�IEDI�ILE E P Y DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT � ESTATE OF: FILE NUMBER: S�� sp �¢/S�7r2 ?.d�3—f>03��. Include the proceeds of litigation and the date the Rroceeds were received by the estate. All property joinHy owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER � DESCRIPTION OF DEATH � �'�SG �� }'" �,►��.ao Q �°.5.�.U �� 9//� �� TOTAL(Also enter on Line 5, Recapitulation) $ � � If more space is needed,use additional sheets of paper of the same size. . • REV-1511 EX+(10-06) . � SCNEpULE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN �QMINISTRATIVE COSTS , RESIDENT DECEDENT ESTATE OF FILE NUMBER S�r� � �� Zol3—�o3�z Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. /�A �"-�/i✓�l� /f� �4�,6,d.3 B. ADMINISTRATIVE COSTS: OflO 1. Personal Representative's Commissions � Name of Personal Representative(s) Street Address City State Zip � Year(s)Commission Paid: 2. Attorney Fees r,�'f(� 3. Family Exemption:(If decedent's address is not the same as claimanYs,attach explanation) 3��,Q�� Claimant �G��"__� �►"" ,�/J �.�1�'�t� StreetAddress 17�' S. �OIp/�� City�� ,�f�-�9'�'�c''`�� State �Zip Relationship of Claimant to Decedent , �' 4. Probate Fees �� 5. Accountant's Fees D�'�� 6. Tax Return Preparer's Fees O,�� 7. TOTAL(Also enter on line 9,Recapitulation) $ 'S� (If more space is needed,insert additional sheets of the,same size) •