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Home My WebLink About01-17-14 � , �c_,�,.;>t-- 1505610101 � : .. , RE1��15@0 ��-�, .� o��sE��Y PA Department of Revenue �,,,,,��a County Code Year Flle Number - Bureau af Ind�ctual Taxes INHERITANCE TAX�RETURN po BoX a�°6°1 RESIDENT DECEDENT Harrisbu ,PA t7128-0601 fNTER DECEDENT INFORMATION BELOW MMDDYYYY Date of Birth MMDDYYYY Sociat Security Number Date of Death Decedent's First Name _ MI Suffix DecedenY's Last Name � � � S (If Applicable)EnterSurviving Spouse's Infomnation Below Suffix Spouse's First Name M� gpouse's t.ast Name a g��$�OqB�Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE � REGISTER OF WILLS y FILL IN APPROPRIATE OVALS BELOW p 3. Remainder Retum(date of death � 1.Original Retum p 2.Suppiemental Retum p��12_��52� p 4.Lim'�ted Estate � 4a.Future interest Compromise(date of O 5• Federa�Estate Tax Retum Required death after 12-12-82) �t Boxes 7.Decedent Maintained a Living Trust 8.Total Number of Safe Depos' � g,pecedent Died Testate � �A��Copy of Trust) (Attach Copy of Wiil) 11. Elecdon to tax under Sec.9113(A) p 9.Litigation Proceeds Received O 10.Spousai Poverty Credit(date of death O �A�ch Sch.O) between 12-31-91 and 1-1-95) POMDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INea�T�Shone �mD�r C�D T0: CORRES D yti P Name � r 9 t GlT � i � � ,, REGIS LLS U�„ONL-� , — � � � V�► - � n � � f"' � � �, '� � `� �t First line of address ,� � � _ 4� � �: � '� — � a � � � = Sec�and line of address :� � �"' "" Se a ., � � � � � � — 7 � N S oA�� State ZIP Code — City or P�t Otfice � ` � � 'C' � i '� b . . - CorrespondenYs e-mail addreas: e and belief, -- u I dedare that I have examined this retum.induding accompanying schedules and statements,and to the best of mY I�o�e�9 — Und e r pen a l tl e s o f p e�j ry� rer other than the persona l r ep r e s e n t ative is based on aH informatlon of which preparer has any knawledge• . it is true,comec:t and complete.Dedaration of prepa . DATE SIG RE OF PERSON RESPONSIBLE FOR FILIN RETl1RN �'� , $'� r - ,�o � /►,p �(3� G l—/� " / — C7 /'� � � � 6 �� DATE g�C,NATURE OF PREPARER OTHER THAN REPRESENTATNE - ADDRESS - � PLEASE USE ORIGINAL FORM ONLY _� _= Side 1 � - ' 1505610101 � - � 1505610101 � _ � U� J 15�5610105 � REV 1500 EX Decedent's Social Security Number •.�x s,aS� .. DecedenYs Name: �� .� `�� " �� ` � � RECaPiTU�ario�v - � � �� °�� :� �� 1. Real Estate(Schedule A). ... .. . . ... . .. .. .... . ..... ... . ... .. . .. .. . . .. . 1. � - � f <; .. �-: .:: ..__.��. �.r� �- �: , �� .,.- �y_ 2. Stocks and Bonds(Schedule B) .. ........ .. .. ..... ... ..... ..... . . .. . . . ' ° � 2. ., . = ' ,�:.:: _ _ ` 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .... , 3 ' a � . � i t . � ` •. .- s 4. Mortgages and Notes Receivable(Schedule D). ..... .... .. .... .... . '� � �� ' ...... 4. :� ;s �s�' ; `- m> 5 � :-: 5. Cash, Bank Deposits and Misceflaneous Personal Pro e x p rty(Schedule E) 5 ' ' ' ` � � � � � . . . ... . 3 . � � : ,- � :., � � : � � � . - =� __ � 6. Jointly Owned Properry(Schedule F) p Separate Billing Requested ... . ... 6, f � � 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property ' �- : � � �` - , _ .;. a, Schedule G) �` � -� ��-�-°=-� p Separate Billing Requested.. .. ... . 7 � = f � , u � .; ,��;� �_ � �; � , 8. Total Gross Assets(total Lines 1 through 7). .. . . .. . � �� ' - � .. ... . . . . .... . . .. . .. . 8 � � ` �f 3 � �, C3� r � . , � ; 9. Funeral Expenses and Administrative Costs(Schedule H). .. . . . � �� . . ... . ... . ... 9 � � �1i 7 _..: _ �� ,'� �f� �r. iG� �� 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) . . . .. . . �� j_ . . . .. . . 10. 4 .. _..:' �u: .... F.�- ` -,- : 11. Total Deductions(total Lines 9 and 10)... . . .. . . .. . .. ... .. . . . .. . . �� - . . . . . . . 11 f 1 � � `a . � ;� a_,� °:s .. r .: , � : 12. Net Value of Estate(Line 8 minus Line 11) . . . . . .. . ... . . . . .. . . . . . . . . � ' �� 'r �` . ... . 12 , � : 13. Charitab{e and Governmental Bequests/Sec 9113 Trusts for which - -� U ' ., ._�: , ; _< _.�-� � . an election to tax has not been made(Schedule J) .. . . .. ... � '�" .. . . ... . . . .. . . . 13. !. �.- ; _ � � � , . � � ___. �.< � Net Value Subject to Tax(Line 12 minus Line 13) ' �� `�� "�� ' .. . . . .. . .. . ... .. . . . . . .. . 14. � � � � � o b , 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_ ' , � � ti _ � � ` � • °�� 15 � � 16. Amount of Line 14 taxab�e `�� - �.��>�. .� = �� ' �� = � �. . _._ ; v . .� � 3 . . � at lineal rate X.0 � � �� '�� - - � � - � • � 16 - �`�� ' - . . � � � � .. �. 17. Amount of Line 14 taxable �-- � �� `� �� -� �� at sibling rate X.12 � � � �`� -� � � ��' - ' '. ' � C/ .� 17. 18. Amount of Line 14 taxable '��' � �� ' � � �� } � � _ . ... - y __ � -- __ .�, �_� �. _ � at collateral rate X.15 � - - _ �_ �.� ' =° 18. } _ 3 __�. _ _>. .., � - _ ..:� , �. . - 4 � ` , ; �_ _.. ___ �___.� _�-. :_;. . ._ � � 19. TAX DUE . ... . . . . .. ... .. ___.... 5_y ... . ... . . .... .... ... . .. ... ... . . .. . ..... .. . 19. � ' 3 ` �., 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT . � Side 2 � 150561,01,�5 150561�1,05 � • File Number ' R�4-�5oC EX`Page 3 ' Decedent's Complete Address: DECEDENTS E � �"` � C�� ,� L �— ,�'`"� l � ' STREET ADDRESS � . STATE ZIP cirr �. - � d s � � �� U Tax payments and Credits: - �� 1. Tax Due(Page 2,Line 19) 2. CreditslPayments A.Prior Payments B.Discount Total Credits(A+B� (2) 3. Interest (3} 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. (4) Fitl in oval on Page 2,Line 20 to request a refund. ` + ' e 3 is reater than Line 2,enter the difference•This is the TA�DUE. �5� 5. If Une 1 Un 9 Make check payable to: REGISTER OF W�LLS,AGENT. � BY PLAClNC AN "X" IN THE APPROPRIATE BLOCKS PLEASE ANSWER THE FOLLOWING QUESTIONS Yes No 1. Did decedent make a transfer and: 0` of the erty transferred;• ............ .................................................. � � prop .................... .. � = a. retain the use or income ............................ b, retain the right to designate who sl�all use the property transferred or its income:................ � ................................... ❑ c. retain a reversionary interest;or....................................................................................... � orcare? ........................................... ❑ d, receive the promise for life of either payments,benefits ••••••••••••••••°°••�••�• did decedent transfec property within one year of death 2. If death occurred after Dec.12,1982, ........ ❑ [� -_• ivin ad uate consideration?......... ...................................:......................................................• � . without rece g eq .. 3. Did decedeni own an"in trust for"or payabie-upon-death bank account or sec t'ty aot eis o�he'ch eath?.....••••••••• 4. Did decedent own an individual retirement account,annuity or other non-proba p P �Y �/ - ............................... ❑ ' desi nation? ......................................... ...................................... contains a benef�c�ary 9 ••••••••° IS YES YOU MUST COMPLETE SCHED!!LE G AND FILE IT AS PART OF THE RETURH• IF THE AHSWER TO ANY OF THE ABOVE QUESTIONS � Jan. 1 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is For dates of death on or after July 1,1994,and before , 3 percent[72 P.S.§9116(a)(1.1)(i)J• - rate im sed on the net vatue of transfers to or for the use of the su�r a��of assets�and For dates of death on or after Jan. 1, 1995, the tax P° u��m�,and the statutory requirements [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a hansfer to a surviving spo • a tax re t um are s ti l l a p p l i c a b l e e v e n i f th e s u rv ivin g s p ouse is the only bene�iciary. _ filing F o r d a t e s o f d e a th on or after Ju l y 1,2000: �m a d e c e a s e d e h►�d 2 1 y e a r s o f a g e o r youn ger at death to or for the use of a natura l paren t, an . The tax rate impased on the net value of transfers adophve parent or a stepparent of the child is 0 percent[72 F•S•§9116(a)(1.2)]. 've = to or for the use of the decedent's lineal beneficiaries is 4.5 perc,ent, except as noted in _ . The tax rate im on the net value of transfers =- 72 P.S.§9116(1.2 [72 P.S•§9116(a)(1)]. cent 2 P.S.§9116(a)(1.3)].A sibling is defined,under - te im on the net value of transfers to or for the use of the decede�ent'�whethe byeblood or adoption. , • The tax ra I� - Section 9102,as an individual who has at least one parent in common with th ' REV-1511 EX+(10-06) SCNEDt�ILE N � WEALTH OF PENNSYLVANIA FUNERAL EXPENSES & COM NHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT FILE NUMBER . ESTATE OF � Debts of decedent must be reported on Schedule L � ITEM DESCRIPTION AMOUNT � NUMBER ' A. FUNERAL EXPENSES: 1. b -�'c�,� (°,�� l�. ��f � � g. ADMINISTRATIVE COSTS: �. Personal Representative's Commissions Name of Personai Representative(s) � Street Address � State Z�p . City Year(s)Commission Paid: 2. Attorney Fees 3. Family Exemption:(If decedent's address is not the same as ctaimanYs,attach explanation). Claimant Street Address State Zip City • . Relationship of Claimant to Decedent �� - � r � 4. Probate Fees � 5. AccountanYs Fees � g. Tax Return Preparer's Fees 7. TOTAL Also enter on line 9,Recapitulation) $ /'/ � �b. 3� ( . REV 1513 EX+(01-10) enns lvania SCHEDULE ] . p y DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER: ESTATE OF: 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).] t�� s;,_�� ' 1�✓r� k-�s�'�-� p _'��..k.�, ,t �. � �1�� - � _ � ` . `c ,�e, �1 m �n p<,�,v� � �-�`�� s u �+' � � � `e ENTER DOL LAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS RPPROPRIATE. 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. -== — TER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ , — TOTAL OF PART II EN If more space is needed,use additional sheets of paper of the same size. REV-1508 EX+(t�-lo) SCNE�DI�ILE E ' � pennsylvania . _ DEPARTMENT OF REVENUE . CASH, BANK DEPOSITS &MISC■ INHERI7ANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT FILE NUMBER: ESTATE OF: , Include the proceeds of litigation a„ttof suarvivorsl'p must be d sclosed on Schedule F. � Ali properly jointly owned with r�g VALUE AT DATE OF DEATH � ITEM DESCRIPTION NUMBER - � ��: f ,e�• . � I�� ? �,. ,�.: (�C k� � �.� � n +� e�v u- �.�- 2 1 c� 3 .Co 0 PN � 13��• C� � , TOTAL(Also enter on Line 5, Recapitulation) $ 02� 3•`� If more space is needed,use additionat sheets of paper of the same size. _ � �. . _ _ ._ • � INVENTORY - REGIS TER OF WILLS OF � tx� v� ,° �-`�'1 Q`"� �' COUNTY,PENNSYLVANIA COMMONW EALTH OF PENNSYLVANIA 1 SS /g5., � fj j 3 .r 4 I a �y C O U N T Y O F J �-�- �U�g File Number Personal Representative(s)of th�Estate of ,�'1 t;i•-� " c�. � � 1-� � �`��. 1� r d de ose s and say(s)that the items appearing in the following inventory include all of the perse�al as�s e each rtem of said decease , p � ) and all of the real estate in the Commonwealth of Pennsylvania of said Decedent,�aattD edent owned no eal estate outside of the inventory represents its fair value as of the date of the�s��a memorandum at the end of this inventory. Commonwealth of Pennsylvania except that which appe , _ I verify that the statements made in this Inven- _ � tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. (Supreme Court I.D.No.) Attorney-- (Name) � (Address) (Telephone) ,� DECEDENT'S SOC.SEC.NO. DATE OF DEATH. LAST RESIDENCE `�� /�//S� � , es � a � /�—. }-�----��{� 1 `3 6 7 6 r e�e�s t n (�F �Pe FIGURES MUST BE TOTALED . � .. , , r � h v� n +a�`/ — �� -- (Attach additional sheets as needed) 0.00 = TOTAL: NOTE: The Memorandum of real e state outside the Commonwealth of Pennsylvania may,at the election of the personal representative include the value of each item,but such figures should not be extended into the total of the Inventory. (See 20 Pa.C.S.�3301(b)) - Form RW-09 rev.10.13.06