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Home My WebLink About03-13-14 c 1505611101 REV-1500 Ex t02-11, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes 1-11"El County Code Year File Number Bu BOX 28ndi i 7;4RITANCE TAX RETURN '�-�r—I� ; Q--7 Harrisburg,PA 17128-0601 RESIDENT DECEDENT j� 10i3 D D-1, /�_j ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name _ Suffix Decedent's First Name MI (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name ` _ Suffix _ Spouse's First Name_ _ rol MII 1( Li _1E _J3 Spouse's Social Security Number �—� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE InQ� � REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 4M 1.Original Return O 2. Supplemental Return C 3. Remainder Return(Date of Death Prior to 12-13-82) p 4. Limited Estate O 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) Q 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 Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name _ _ _ _ Daytime Telephone Number � .eor�E�y�i.��Q °i_ii/_11:!j-JI.��'�Je;_r i �I _ �_J�� _�i_�:.�kQ� 117 .(J17�'�?►7"P13,x. REGISTE CE LLS USE�LY ,{ b-T1 C First Line Address ' r i� GJ 7J t. _i�b ,�_ h�:.� .t_ nl�- ��'�+ �� d,I_�I�Q o� P? Second Line of Address_ __ _ _ _ :X ' •--•� Q -- n Q=,I L_1+ J IL l Ln City or Post Office State ZIP Code DATE FILED JL 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. M U E OF PERSON ESPONSIBLE FOR FILING RETURN DATE ADDRESS 92 SIGNATURE OF PREPA ER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611101 1505611101 �V� 1505611201 REV-1500 EX Decedent's Social Security Numberp. Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ......... .... .... .......... .... ........ ....... 1. 2. Stocks and Bonds(Schedule B) .... .... .... . .... ..... .... . ... .... .... . 2. 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. 6. Jointly Owned Property(Schedule F) O Separate Billing Requested . ... ... 6. 7. Interu Transfers 8 Miscellaneous Nan-Probate Property --t�y��• (Schedule G) O Separate Billing Requested.. ... . .. 7. 8. Total Gross Assets(total Lines 1 through 7).... . ..... .... ....... . .... ... 8. _��._� ++ 9. Funeral Expenses and Administrative Costs(Schedule H)..... ... ..... ... . .. 9. I.1 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). ... . .... ..... . 10. 11. Total Deductions(total Lines 9 and 10). ... . .... ..... ..... . ........ ... . .. 11. (, 12 Net Value of Estate(Line 8 minus Line 11) . . .... . .... ..... .... .... .... .. 12. ' 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which - -� an election to tax has not been made(Schedule J) ..... .... . . .. ..... ..... . 13. •�7 14. Net Value Subject to Tax(Line 12 minus Line 13) . . .... .... . ... . ... .... . . 14. �- TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable atthe spousal tax rate,or transfers under Sec.9116 �I '(a)(1.2)X.O-Z.$ l.r..�� 15. (- �,• �j 16. 'Amount of Line.14 taxable - i �-, at lineal rate X.0_ r.�� 16. �.IL r 17. Amount of Line'14 taxable it sibling rate X.12 17. 18. Amount of Line 14 taxable - - at collateral rate X.15 [ 18 1 l t -1 r1 19. TAX DUE . .. ... ... . ... . .... .. . ... . .... . .... ..... ..... .... .... . .... 19. ( I • z 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505611201 1505611201 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME r-- STREET ADDRES8 Gr �h Ut 0 % 4'6Yt o4 CITY STATE ZIP P4< Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) {�) 2. Credits/Payments 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 ' No a. retain the use or income of the property transferred...............................................................I.......................... ❑ b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ c. retain a reversionary interest .............................................................................................................................. El 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?.............................................................................................................. ❑ 2 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?............. ❑ c . 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa beneficiary designation? ........................................................................................................................ ❑ S. 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 adaptive 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(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(x)(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. l COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No. CD 017084 MILLER PAUL A 1235 DOUBLING GAP ROAD NEWVILLE, PA 17241 ACN ASSESSMENT AMOUNT CONTROL NUMBER 12169468 { $17.23 ESTATE INFORMATION: SSN: FILE NUMBER: 2113-0087 DECEDENT NAME: JOHNSON MAUDLEEN J DATE OF PAYMENT: 01/23/2013 POSTMARK DATE: 01/22/2013 1 COUNTY: CUMBERLAND DATE OF DEATH: 10/25/2012 TOTAL AMOUNT PAID: $17,23 REMARKS: PAUL A MILLER CHECK# 1086 INITIALS: WZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER ~� 1 / I % ) { 1 Z//.L•��- CD V L:_ • L.L.s 1..I..J ..... 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