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Home My WebLink About04-04-14 J 1505611101 REV-1500 EX(02-11) OFFICIAL USE ONLY PA Department of Revenue pennsytvania Bureau of Individual Taxes . County Code Year File Number PO BOX 90601 INHERITANCE TAX RETURN MOM !` Harrisburg, 17128-0601 RESIDENT DECEDENT � t I � V ,� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDOYYYY /VaV52ol 2 ,661,2 1 9 ! R33 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 MI LL b TH 9 UJ'r R ® ME rZ AFL DT1TT7 F1 Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ✓.-b 3 Na 1(�1- '1 A& `� REGISTER OF WILLS FILLIN APPROPRIATE OVALS BELOW GIR 1. Original Return O 2. Supplemental Return O 3. Remainder Return(Date of Death _Prior to 12-13-82) C 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes w . (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 0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytim Telephone NunVmr 70 t�v4 p L; AIL o T L:R _ o o� C RE OflWILL' S 0N{-1C:) D r rn rn First Line of Address Z (P C) C:)532 Mo u��UTA r N R ag D � `� � -n Second Line of Address ` rn0 ED Y. D tV City or Post Office State ZIP Code DATE FILED D; %,� L S B cc�RG P A l 7,.o 1 9 s m �. o Correspondent's e-mail address: a ro C> .-4 C Under penalties of u I declare that I have examined this return,including accompanying schedules and statements,and to the f ed e d b 11 P, Pad m 9 9 ?n .O it is true,corteU and complete.Declaration of preparer other than the personal representative is based on all information of which pr r a y kn w ledge. ; SIGN RE OF SO ES B OR FILING RETURN Z DAT -n '- 'rl ADDRESS �'-� '.� r_ fn i o *� SIGNATURE OF_PREPARER OTHER THAN REPRESENTATIVE ?DATE Lin ADDRESS PLEASE USE ORIGINAL FORM ONLY r Side 1 L 1505611101 1505611101 1505611201 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ..... .. .............. 0. 0 C;) 2. Stocks and Bonds(Schedule B) ......... ................. .... ......... 2. 1 Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. . 3. 4. Mortgages and Notes Receivable(Schedule 0). ....... 4. 0 .0 0 S. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . ... . 5. 0 . 0 0 6. Jointly Owned Property(Schedule F) C=D Separate Billing Requested ....... 6. 0. G 0 7. Inter-Vvos Transfers&Miscellaneous Non-Probate Property (Schedule G) I= Separate Billing Requested.. .. .... 7. Q. 0 0 8. Total Gross Assets(total Lines I through 7)...... ......... 8, 9. Funeral Expenses and Administrative Costs(Schedule H). ... ... ... ... ... ... 9. 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 6.0 0 11, Total Deductions(total Lines 9 and 10). ... ... ... ... ... ... ...... ... . . . . . 11. (). 0 0 12. Net Value of Estate(Line 8minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. . ..... . .. ... ... ... .. .. 13. U. G 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 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_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 17, 18, Amount of Line 14 taxable at collateral rate X.15 19. TAX DUE .. . ..... ... ... .. . .. . .. .. . . .. ... ...... . .. ... . . .... . .. ... . . 19.. 0 0 20.,FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=D Side 2 1505611201 1505611201 REV-1500 EX Page 3 Fite Number Decedent's Complete Address: DECEDENT'S NAME STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0 - 00 2. Credits/Payments A.Prior Payments S.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...................._............................................___....___..... ❑ ❑ b. retain the right to designate who shall use the property transferred or its income ...................._...,............._.. ❑ ❑ c, retain a reversionary interest .............................................................................................................................. ❑ ❑ 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. 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 lax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent 172 P.S.§9116(a)(11)(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(a)(1)). The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent 172 P.S. §9116(8)(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. wy C N C a flu O i•y G p fLO � O o nQ -h lag ° F ran c�a r� l� C- ° �v c> o VO m Op m ^n r— M au, � o °n n o oc -A � � 4 lid � O �M u �o 0 ^mT J W O v r o{�} ga_NyN