Loading...
HomeMy WebLinkAbout03-14-14 s 1505610101 REV-1500 EX(°I-,o) OFFICIAL USE ONLY PA Department of Revenue pennsytvania OEV�NTMEMOf NEVENUE County Code Year File Number Bureau of Individual Taxes � PO BOX 28o6oi INHERITANCE TAX RETURN P13LE1112 -Harrisburg,PA 17128-06oi RESIDENT DECEDENT 1111 IJL_3I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY �� �� oa❑a���o � Lid) i9__13Go3>��13J6J Decedent's Last Name Suffix Decedent's First Name MI ���iJ���O) ►❑�l%1❑❑❑❑❑❑ 1111❑ ®�D��❑OD❑❑❑❑ (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ID 0❑❑❑❑❑❑1111❑❑❑❑❑ ❑00 ❑❑❑❑❑❑❑❑❑❑❑❑ ❑i Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE U❑❑Y❑Ur�-JU❑❑ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW IM 1.Original Return O 2.Supplemental Return O 3. Remainder Return(date of death j prior to 12-13-82) ® 4. Limited Estate O 4a. Future Interest Compromise(date of O. 5. Federal Estate Tax Return Required death after 12-12-82) ® 6. Decedent Died Testate 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.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 11+�❑❑iJ❑❑❑❑U❑❑J❑❑❑❑IJ❑❑❑❑❑ FLI Ll LH__J 0J111 REGISTER OF WILLS L.5§ONLY n 0 First line of address CID rn _' LID Ll 11 11 J 11 Second line of address V - ©C.) O[W_E FILED N City or Post Office State ZIP Code - J ❑JiJJ❑0Ll0IJ❑❑❑U❑ J❑ FiJ❑❑❑J❑J1� �' Correspondent's e-mail address: Under penalties of perjury,I declare that I have examined this return,including 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. SPGk0FURE OF PE SPO I OR FILING RETURN D )�/, f ADDRESS S U OF PREPA R T 1 l ADDRES$ t 6-4 PLEASE USE ORIGINAL FORM ON Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: �- RECAPITULATION w 1. Real Estate(Schedule A). ......... ...... 1. (� •/q . 2. Stocks and Bonds(Schedule B) . ...................................... 2. v _�01 3. Closely Held Corporation;Partnership or Sole-Proprietorship(Schedule C) ,.... 3. • 4. Mortgages and Notes Receivable(Schedule D). ............. .... ......... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).,..... 5. • {1 V 6. Jointly Owned Property(Schedule F) .p Separate Billing Requested ....... 6. •� 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property " (Schedule G) p Separate Billing Requested........ 7. �•i- 8. Total Gross Assets(total Lines 1 through 7). ..................... ....... 81 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. a 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .... .......... % 11. Total Deductions(total Lines 9 and 10)............... .............. 11, a c 12. Net Value of Estate(Line 8 minus Line 11) ... ......... ................ .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which gn election to tax has not been made(Schedule J) ........................ 14. Not Value Subject to Tax(Line 12 minus Line 13) ............ ... ........ . 14. 3 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. 16. Amount of Line 14 taxable at lineal rate X.0_ I& 17. Amount of Line 14 taxabla at sibling rate X.12 17. 18. Amount of Line 14 taxable O at collateral rate X.15 18. T J, I'll ­ � :_. 19. TAX DUE,.......... .. ........ ... .... ............ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1500 EX isage 3 File Number Decedent's Complete Address: DECEDE T'§NAME STREETADDRESS 6 & J54 CITY STA7Ej ZIP Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (.1) 2. CreditsfPayments 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. 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 a. retain the use or income of the properly transferred:.............................................,............................................ E b. retain the right to designate who shall use the property transferred or its income;............................................ CR El c. retain a reversionary interest;or.......................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ Q 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)(i)]. 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 filing 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(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 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. REV-1502 EX+x(01-10) pennsytvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined 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 facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. TOTAL(Also enter on Line 1, Recapitulation.) $ If more space is needed,use additional sheets of paper of the same size. REV-1503 EX+(6-98) .a SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1504EX+(1-97) SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent,other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships. 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) REV-1505 EX+16-98) SCHEDULE C-1 CLOSELY-HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1: Name of Corporation State on Incorporation Address Date of Incorporation City State • Zip Code Total Number of Shareholders 2. Federal Employer I.D.Number Business Reporting Year 3. Type of Business Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VotinglNon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK j Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 7. Was there life insurance payable to the corporation upon the.death of the decedent? . . . . . ❑Yes ❑ No If yes, Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. 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 Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? :...❑Yes ❑ No If yes, provide a copy of the agreement. 10.Was the decedent's stock sold? ........................................ ............. ❑Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ................. ❑Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 12.Did the corporation have an interest in other corporations or partnerships? ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION A. Detailed calculations used in the valuation of the decedent's stock. B.. Complete copies of financial statements or Federal Corporate Income Tax returns(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/es and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. List of principal stockholders at the date,of death,number of shares held and their relationship to the decedent. E. List of officers,their salaries,bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year.List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed,insert additional sheets of the same size) R6.1506 EX+(9-00) �b- SCHEDULE C-Z COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN RESIDENT DECEDENT INFORMATION REPORT �[ ESTATE OF FILE NUMBER -1. Name of Partnership Date Business Commenced Address. Business Reporting Year City State Zip Code 2. Federal Employer I.D.Number 3. Type of Business Product/Service 4. Decedent was a ❑General ❑ Limited partner. If decedent was a limited partner, provide initial investment$ 5• PERCENT PERCENT BALANCE OF PARTNER NAME OF INCOME OF OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest$ 7.. Was the Partnership indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . ❑Yes ❑ No If yes,provide amount of indebtedness$ 8. Was there life insurance payable to the partnership upon the death of the decedent? .... . ❑Yes ❑ No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership 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 Percentage transferred/sold Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 10.Was there a written partnership agreement in effect at the time of the decedent's death? . . . . :. ❑Yes ❑ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ... . .. . ....... .. . ...... .. . ..... .. . . . .... . ❑Yes 0 No If yes,provide a copy of the agreement of sale,etc. 12.Was the partnership dissolved or liquidated after the decedent's death? .... .. .. . ...... .. .. ❑Yes ' ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and'amounts received. 13.Was the decedent related to any of the partners? ... .... .. .. .. ... .. . . ..... .. . . .. . .... ❑Yes* ❑ No If yes, explain 14.Did the partnership have an interest in other corporations or partnerships? .. ..... .. .. .... ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns(Form 1065)for the year of death and 4 preceding years. C. If the partnership owned real estate,submit a list showing the complete addresses and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX#(1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. t TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-15o8 EX+(ii-io) pennsylvania SCHEDULE E Q/ DEPARTMENT OF REVENUE CASH,- BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: 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 NZ DOD l o qS JAW, 00 TOTAL(Also enter on Line 5, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. REV-i5ag EX+,(oi-io) pennsylvania •SCHEDULE F . DEPARTMENT OF REVENUE f ` INHERITANCE TAX RETURN'. JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: If an asset became jointly awned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING.JOINT TENANT(S)NAME(S)- ADDRESS RELATIONSHIP TO DECEDENT A. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %of DATE OF DEATH. ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT'NUMBER OR SIMILAR' DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. i. F 't t . k } 1 t C t t TOTAL(Also enter on Line 6, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) � pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND ' INHERITANCE TAX RETURN ADMINISTRATIVE COSTS �d ' vim'a RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER `DE_S�CRIPTION AMOUNT A. FUNERAL EXPENSES: �J-�,LpILti1d1A�� 1. �. &55 ®4 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) 1 Street Address City o g , State ZIP Year(s)Commission Paid: 2. Attorney Fees: n 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 00 4. Probate Fees: Q(`� 5. Accountant Fees: Q� 6. Tax Return PreparerFees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 00 If more space is needed,use additional sheets of paper of the same size. REV-'1512 EX+'(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT / n INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS 'Ar1l RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 1. i TOTAL(Also enter on Line 10, Recapitulation) $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE ,�/,3 INHERITANCE TAX RETURN BENEFICIARIES a �'� co Ll� 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.9116(a)(1.2).] 1. � • W 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. REV-1514 EX+(12-03) SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN 4 INHERITANCE 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 calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ❑ Will ❑ Intervivos Deed of Trust ❑ Other CALCULATION LIFE ESTATE INTEREST NAME(S)OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . Interest table rate—❑ 3 1/2% ❑ 6% ❑ 10% ❑Variable Rate 3. Value of life estate(Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ CALCULATION ANNUITY INTEREST NAME(S)OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) . . . . . . . .. . . . . . . . . . . . . . . . . . Frequency of payout—❑ Weekly(52) ❑ Bi-weekly(26) ❑ Monthly(12) ❑ Quarterly(4) ❑ Semi-annually(2) ❑ Annually(1) ❑ Other( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Annuity Factor(see instructions) Interest table rate—❑ 3 1/2% ❑6% ❑ 10% ❑Variable Rate 6. Adjustment Factor(see instructions) . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . 7. Value of annuity— If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . .. . . . .$ NOTE:The values 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 return.The resulting life or annuity interest(s)should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size) REV-1644 EX+ (01-10) ] 7 pennsytvania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L INHERITANCE TAX RETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION'OF TRUST CORPUS I. ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents dying on or before Dec. 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) of Election or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . .$ 3. Closely Held Stock/Partnership . . . . . . . . . . . . .$ 4. Mortgages and Notes . . . . . . . . . . . . . . . . . . . .$ 5. Cash/Misc. Personal Property . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . .$ 2. Unpaid Bequests . . . . . . . . . . . . . . . . . . . . . . .$ 3. Value of Non Includable Assets . . . . . . . . . . . . .$ 4. Total from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . .$ F. Remainder Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . G. Taxable Remainder Value (Multiply Line E by Line F) . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Remainder Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) " ??EV•18t5 EXi{7.85) ' INHERITANCE TAX SCHEDULE L-1' , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTIONa�"I. RESIDENT DECEDENT -ASSETS- FILE NUMBER a I. Estate of _ _ Nana) (First Name) (Middle Initian !1. Item Na . Description Value A. Real Estate (please describe) 00 Total value of real estate S (include on Section 11, Line C-1 an Schedule L) (p B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Section 11, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C•1 and/or C-2) (please list) Total value of Closely Held/Partnership $ (include on Section II, line C•3 on Schedule L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section It,Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) C91� R311 l a63 06 Total value of Cash/Misc. Pers. Property $ CJ (include on Section II, Line C-S on Schedule L) 111• TOTAL (Also enter on Section 11, Line C-6 on Schedule L) $ (If more space is needed, attach additional 81/2 x 11 sheets.) REV-1646 EX,+ (11-09) pennsytvania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L-2 INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- I. ESTATE OF FILE NUMBER II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Assets Reported on Schedule L-1 (other than unpaid bequests listed under"B" above) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L) TII. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV11647 EX+1(02-10) pennsylvania SCHEDULE M DEPARTMENT OF REVENUE FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN ao �a13 RESIDENT DECEDENT (Check Box 4a on REV-15oo) ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents who died after Dec. 12, 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 possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. :l Will ❑ Trust ❑ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. t dA 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise 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 exercises such withdrawal right. ❑ Unlimited right of withdrawal ❑ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) . . . . . . . . $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1.taxable at lineal rate Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) . . . . . . . . $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . $ If more space is needed, use additional sheets of paper of the same size. REW1649 Ek+`(08-09) pennsylvania SCHEDULE O + DEPARTMENT OF REVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC.2ii3(A) RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS) ESTATE OF 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 filed for each trust. This election applies to the Trust(marital, residual A, B, by-pass, Unified Credit,etc.). If a trust or similar arrangement meets the requirements of Section 2113(A)and: a.The trust or similar arrangement is listed on Schedule 0 and b.The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,then the transferor's.personal representa- tive may specifically identify the trust(all or a fractional portion or percentage)to be included in the election to have such trust or similar proper- f 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 I' Schedule 0,the.personal representative shall be considered to have made the election only as to a fraction 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 in Part A for which the Section 2113(A) election to tax is being made. Description Value Part B Total $ If more space.is needed,use additional sheets of paper of the same size. COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, LISA M. GRAYSON, ESQ. Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 7th day of March, Two Thousand and Fourteen Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of ALICE FAY HEBERLIG late of LOWER MIFFLIN TOWNSHIP (First,Middle,Last) in said county, deceased, to KELLY M SHIELDS (First,Middle,Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 7th day of March Two Thousand and Fourteen. File No. 2014- 00213 PA File No. 21- 14- 0213 Date of Death 111312014 S. S. # eghsty of Wills AA �^VvY De ty NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL