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HomeMy WebLinkAbout05-07-14 S, I� �{ 1505610105 REV-1500 EX'02-r"tFD'W PA Department of Revenue pennsylvarda OFFICIAL USE ONLY Bureau of Individuat Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601. 2 1 I 2(Q d _ Harrisbur PA 17128-01 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 01 /2q/u� 14 03��R� IRaq Decedent's last Name Suffix Deced nt's Fi Name MI Wo Lco- L y ��q N (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 4W 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a.Future Interest Compromise date of P ( O 5. Federal Estate Tax Return Required death after 12-12-82) O 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust D 6. 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 turfi^({seVl -717-- 677-67'7 REGISTER OF WILLS USE ONI!n� C> First Line of Address rn C> Cd 3 7 S'_ LekA-S.he( r� Second Line of Address ~ m 3C7 V 7 �I City r Post Office DATE FFLIED'i; -� Y State ZIP Code - �lilecl�aviics6cry _ 7055' Correspondent's e-mail address: klk�r USP m d✓m 0 verT oom mf Under penalties of penury,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.Dedaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE '7OF-'PERSON RESPONSIBLE FOR FILING RETURN / �yr�f Q {I1 / /// DATE� ,/ ADDRESS J / /M'\/�/^//n�yl`�SfJT/l}/M —/U� �I SIGNATURE OF PREPARER OTHER THAN REPRE ENTATIVE ' DA7 ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J e� 1505610205 REV-1500 EX(FI) `,y Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ... . . ... . ... .... .. . . .. . . .. . . ................ 1. O 2. Stocks and Bonds(Schedule B) ........ ........ .. . . . . . . .. . .. . .. . ...... 2. O 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. D 4. Mortgages and Notes Receivable(Schedule D).......... . .......... . . . . . . 4. V 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 0 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ... . . 6. V 7. Inter-Vitus Transfers&Miscellaneous Non-Probate Property 3 7' blV (Schedule G) O Separate Billing Requested... . . . . . 7. / 8. Total Gross Assets(total Lines 1 through 7). . .............. ...... ....... 8. -3171 6�l 9. Funeral Expenses and Administrative Costs(Schedule H). . ... ....... ....... 9. CJ q56 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1).... ....... .... 10. 20, 0 G 11. Total Deductions(total Lines 9 and 10)................................. 11. •z- 12. Net Value of Estate(Line 8 minus Line 11) .. . ............ .. . . ... ... . .. . . 12. 2 R c r Z f 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ........... . ...... .. .... 13. O 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. at Amount of collateral ate Xt 15 axable Ci l( O 18. `7 3/ 6617 19. TAX DUE ........ . . . ............ . .. .. . . . .. . . .. .................... 19. 31, 6 6 t 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME L i q k_ vo [ co ft STREETADDRESS ©O ! A i p N CITY { ` STATE ZIP a q-1 c& ur 0S5 Tax Payments and Credits: rl ! ry 1. Tax Due(Page 2,Line 19) 0) `f (� `� 2. Credits/Payments e A.Prior Payments B.Discount S b ^� q Total Credits(A+B) (2) L (J 3. Interest 111 (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) ,r 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) �( r 4 1 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.......................................................................................... El b. retain the right to designate who shall use the property transferred or its income ............................................ 1:1 c. retain a reversionary interest.............................................................................................................................. 1-1 d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ m 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death / without receiving adequate consideration?....................................................................r .C.�'....,:4,et .. El LSI 3. Did decedent own an*m trust for'or payable-upon-death bank account or security a is or her death?.............. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designallon? ........................................................................................................................ ❑ 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 172 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-1510 EX+(08-09) i�i; pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INMEMANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Lydiq k - Wo I (off. This schedule must be completed and filed If the answer to any of questions 1 through 4 on page three of the REV-15001s yes. ITEM DESCRIPTION OF PROPERTY fuauoE THE WE OF THE TPANSFEJ EE,THEIR taATIONSHIP TO DEEEDDD AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF mANSFEL ATTACH A COPY OF THE DEED Not REAL ESTATE. VALUE OF ASSET INTEREST (IfA cAaIE) VALUE 1- pF,zer -Tvic., SYAghol PFEy (v 'P-4� 7170-91103, SSt Shares X#3d-jjfe,5h4tr a14eA:: �47�6gj 100 U 317 6?1 Brokeru� 1}crot�nf was re' `ls��rc� I reAS70ler on death 10 jhP S in0rjvldi[el j 713-1'cd Oil S'chtthu (e 7 TOTAL(Also enter on Line 7, Recapitulation) $ [ ®9B If more space Is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX DECEDENT URN RESIDENT DECEDENF ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. D<-Y446 CerTA(-p t—> C/emgiivny Unj burial plot ohd 41996 hill +mefltt$Mone� cd Wralt(sjrtgr Ptvil Yl✓Qhly e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: Z, Attorney Fees: 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 4. Probate Fees: 5. Accountant Fees: A k�; HQ if r A(ef&( 1/ D� 6. Tax Return Preparer Fees: 1 7. Pes7nsrlvgtiRr Y�e�,cP �.p�nuP 2n(3 �vtcYl ' ix �' �C 1, �Of1 TOTAL(Also enter on Line 9, Recapitulation) $ b� 7 REV-1512 EX+ (12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF L, d ( � \A,1 6 (C o j� 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. &(QnCe o tvr4 Ae-e fqh \1 tlgye 20 ® 16 Care Pr(o/\ ` c) d(!Nfk aA� V1fle,, 44fa cte&A rn011th r Z � Ay_ C£ hCj0sj,-gACC1j4C6Th) 2. Fflig( Phorwc 9W 3F TOTAL(Also enter on Line 10, Recapitulation) $ Z�/l�0• If more space is needed,insert additional sheets of the same size. o REV-1513 EX+(01-10) I� pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAR RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(5)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Set.9116(a)(1.2).) Dabl�H,N. � �q17 Co�sih �f Iq ro 2 kur+ l#rusev) 13 7 S-LeWk&berr7 Pd'f COvSIn 4 �� Mech4n)cs6ttryf P,4- 1705S- '3- LPshc C Alms o, m. Rovslod1/ Te)co cousiH 90 4_ -,�e( t 10'rvsP� 13 b 6 0 Co lISO ft G/eY C G Lj s sah b eya C14 . 4 2 13 0 S ice fficolmo 2S061v Wortti;Eton CousM lyro Fay,efficv( lIP fir--Z 2703 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. Check Image { in o C U p� /age 1 of 1 , 5 Check Image r—hT l r' xY l Y l,X:� --Q-N1, YI Print AtCOU EN---""" ��[MST THIS PAYMENT MR OUR MUTUAL CUSTOMER S10,638.76 k: smosm . 0—co-irt- Please Direct Any Ouesbons To 7815/360 1 Crime Bill Payment Processing Center 0000005036 I KUR US EN OVM (W)141-not i 137 S MECHANI I RD February 04. 2014 CITIZENS BANK PayTEN THOUSAND SIX HUNDRED THIRTY EIGHT AND 751100----- DOLLARS l•Intl•NhIbllnall•natbhll••PhdPII••IPhPlqu31•I $ •'••10,638.75 0"WIA80401 ADC its X06460 2770343 001 080005 0000]/0000] Void After 180 DAYS. 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