HomeMy WebLinkAbout03-11-14 J 15056101�1
REV-1500 �``°i-'°, �'
enns lvania OFFICIAL USE ONLY
PA Department of Revenue p y County Code Year File Number
Bureau of Individuat Taxes �Mp�MFNTOFqEVENUE
Po a0x Z8o6o1 INHERITANCE TAX RETURN
Harrisburq,PA i�i28-o601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
.� ,�, ;�. v�r _
' � � / 7 �� � Q � � • 1� � • A
DecedenYs Last Name Suffix DecedenYs First Name MI
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� If� � � �a��...��
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
������ _��e
Spouse's Social Security Number
� THIS RETURN MUST BE FILED IN DUPLICATE WRH THE
.�,, ,,,�, ,,, � �� REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return p 2.Supplemental Return p 3. Remainder Retum(date of death
prior to 12-13-82)
p 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 O 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
Q 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A)
beiween 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE OIRECTED T0:
Name Daytime Telephone Number
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REGISTER OF WILLS USE ONLY
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First line of address n '�
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Second line of address �--R � c � �
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City or Post Office State ZIP Code . •FILED -� _:�
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Correspondent's e-mail address: �'J/?j ry1�,2 ���r�� �n/�y!/� r� �r, rJ1"�
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 true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowiedge.
SIGN OF PEgs ON ESPONSIB F R FILING RETURN DATE
../e i`�- i7��'l2.dcn� �3 1.� -/'�
AD)DRES� -� -
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SIGNATURE OF PREPAR R OTHER T N REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610101 1505610101 �
� 1505610105
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: �� / .,:� �� ����
RECAPI7ULATION
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, =�r.
1. Real Estate(Schedule A). .. . .. ...... . .. .. .. ............ ... .. ....... .. 1. . �-
� . . . _��,.; .,, , .;,
2. Stocks and Bonds(Schedule B) . . ... ... ............. ... ... ............ 2. +
-� _ ��. ,:.m ���
3. Glosely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. ��
�. .�. - . F�.
4. Mort a es and Notes Receivable Schedule D 4. r
ss ( ) ... .. ....... ... .. ... ...... Q
_�
5. Cash,Bank Deposits and Misceilaneous Personai Property(Schedule E)...... 5. .�
�� �
x x _�«�-
6. Jointly Owned Property(Schedule F) p Separate Billing Requested ...... 6. r; �
7. Inter-Vivos Transfers 8�Misceilaneous Non-Probate Property � �'' '= '� "
(Schedule G) p Separate Billing Requested........ 7. < j � F �,.
�
.,,... = __�:_
�8. Total Gross Assets(total Lines 1 through 7).. ..... ...... .... ...... .. ... 8 � , � .
_. . _ _.. °
9. Funeral Expenses and Administrative Costs(Schedule H)..... ............. 9 ��: � ���`
° ,�d ,�,�-
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) ........ ... . .. 10. r # �
_: .�T.w �x- „
11. Total Deductions(total Lines 9 and 10)... . . ... .. ......... ... . . .. . . ..... 11. � � �0�$���;'
���
12. Net Value of Estate(Line 8 minus line 11) . .. .... .. ... . .. ... .. ......... 12 „���'
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which ����-° � � � �� '�`'���` "�x��`��~'
an election to tax has not been made(Schedule J) .. .. ........ . . .. .. .. . . .. 13. , ; °:' =� ~` `
_... . :, ...
14. Net Value Subject to Tax(Line 12 minus Line 13} .. .. .... ..... . .. .... . . .. 14. �pV�,� �
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 °. _ � � . . -�� Y==.�� �>.�^ ��.�;_-� ,.��, � �n��� �°.-.,
�a)�1.2)X.0- x � 15. ' � �.
16. Amount of Line 14 taxable * };�� � °`
at lineal rate X.0_ �. 16. ; �i.
17. Amount of Line 14 taxable �� ' ""�" ' � ��'--x� � '� ` �"�� � '�'"
K � s ` #
at sibling rate X.12 x � ~ ' 17 { _
�'¢�3�-�., f��;�._'� �i:,�" �� <�. "��..� .'--:�5�-�r�:.
18. Amount of Line 14 taxabie �; � , _
at collaterai rate X.15 � 18 ' -
x �
. ,.� `> �� ' ::�� ° ;�° < �� � * ��
19. TAX DUE .............. .......................................... 19.* ; '�
�. .���`-�;�
20. FILL tN TttE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 1505610105 150561�105 J
REV-150G EX Page 3 File Numbar
Dec�clent's Complete Address: � �'�� � �/���
DECE T'S NAME
.
.
T r'�E'rl�—�--�J/ l'
STREET ADDRESS
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X �1"G�.P��t f—�r" ���/��
�
- ----
CITY�r�I��G' � i STATE a ------ i 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) G
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.
h �-"' �� �x, �'.� � • *� �#,33 w�' c'�--•��-�"-, �' �"' .� s .a. a�� a�p'�€. �fl^ c-x - -_
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_ . �._,v .`���. _^:'i ,'_.o�r'..+. �� :a -r'�Y�-�.._`� ��u��. �. � ,,�w. w � . �.uv, .. Q_ .�.��. . �.' .
a'� ..r-. .z�.�"1„€ ...����4EI`' , "z'�....'� T.,��` _ v ...,..�.v. `'E�: _ .
PLEASE ANSWER THE FOLLOWING QUESTIaNS 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:..............................................................:........................... ❑ �
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?...................................................................... ❑ �
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.
.. .., p&aJX 4 "� �'.°;_ °=' . . -.. '�= � "'4a i�i,.te 5$A':
��? ��..sm-�:�;ss. . . s rc�.rv���z . a�at.��� ._,�:. : ��a.���";:r 4°"�:,i"?�£"'��-�u',��21:C"4�P`��.�„?..:w. ,sz�..� �-�,�a.�v�-#:4.:;?, .. 3.
'_�,�"a^€ _
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 decedenYs 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.
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INHERITANCE TAX RETURI� I �[}{1/�{NIS�TRATI�E CC�rSTS
RESIDENT DECEDENT I i
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�STATE OF FiLE PdUft18ER
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Debts of decedent must be reported on Schedule I.
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