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Home My WebLink About05-06-14 � 1505610105 REV-1500 EX(02-u)(FI) � PA Department of Revenue pennsylvania OFFICIAL USE ONLY �fPa�=�� «_��,- County Code Year File Number Bureau of Individuat Taxes INHERITANCE TAX RETURN Po BoX z8oso� 2r �� _��z Harrisburg,PA 1�128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social � � ��6 zai� 07 _ Q 3 Ig��o : DecedenYs Last Name Suffix Decede Ys First ame MI _ /� �� J� _ 9�2 �j 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 !� i.Original Return p 2.Supplemental Return p 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate p 4a. Future Interest Compromise(date of p 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 (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 T0: Name Daytime Telephor.e lVumber _ �.aR� ��. 6��r��. � ��-�� 717 - ��3 -�7� Z REGISTER OF WILLS USE ONLY r�a � L,� First Line of Address �- _..c � � -� CJ ''� f'3 �� L,ar� �o�� C� �� -� �, ___ � r"�7 � � --c c.,LLa .�7 5econd Line of Address � ,.,� r— -, G _ _ __ .- , ..�.� _ _ w �... ,, _.. ' CT� ,J , , . w,� . . -. ; _ . ;:,. ,, :_:� City or Post Office _ __ te ZIP Code -::? .. _ DAT ED_ ' -- � _ / ::7 � � _� E� "7 ...� ..._ `T7 _ � � �� ' � �0 / ='� 1 H-, ,�= c� --f '_�_ M 't7 C_ ys O Cn � CorrespondenYs e-maii 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 befief, it is true,correct and complete.Declaration of preparer other than the personal presen ative is ased on all information of which preparer has any kr,owledge. SIGNATURE OF PERS N RES NSIBLE FOR FILING RETURN � ��-N� DATE v�Z � • �.�t/�/O/L X V/Y/( t.y Z(, � � ADD SS �t " �3 r�i� � l� �.-� �,� �l-�- (rl� I� SIG ATURE OF PREPARER O HER THAN REPRESENTATIVE T— � DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 15D5610105 � � J15�5610205 REV-1500 EX(FI) DecedenYs Social Security Number _... �(� ', DecedenYs Name: RECAPITULATION 1. Real Estate(Schedule A). . . .. . ... . . .... . .... . ..... .. . .... ... . . . .. . ... 1 l 2 ( �"l"O� . _. ...... _.: 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 Personai Property(Schedule E)...... . 5 ( � � � � �__� `(� � _... ..�,....._..... ; 6. Jointiy Owned Property(Schedule F) O Separate Billing Requested . ... ... 6 ; „_ ...._........... 7. inter-Vivos Transfers&Miscelianeous Non-Probate Property (Schedule G) O Separate Billing Requested.. ...... 7 s ,.......,_ _._._......, .._.. _... ,,,.._... 8. Total Gross Assets(total Lines 1 through 7}. ......... . .. ........ .. . .... . 8 � � ( � 3 L-- 9. Funerai Expenses and Administrative Costs{Schedule H). .. .. . . . ..... . .... . 9. , � � � � ' . , / ' 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). .. .. . .... . .... 10 � � � � ��: � / # 11. Total Deductions(total Lines 9 and 10). ..... ... ..... . . . . . ... .. ... .. . ... 11 �� ^ 12. Net Value of Estate(Line 8 minus Line 11) .. ... .... . .. ..... . .. . .. .. ..... 12 / �� , ' , ... sL=__�.�,,. „ .__ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .... . .. ..... . .. . .. .. .. .. 13 " � d . �,�D��,� �� ee 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 �_�.... .. ...... . ..... .. _.�. e....». �, a.. e. e� �.... 16. Amount of Line 14 taxable 16 ' at lineal rate X.0_ �' �� -�,��- - -� �.�� .. A.�...... ��... ... .m.�..� 17. Amount of Line 14 taxable , at sibiing rate X.12 ' .._. _i ._._,.,..:�....„...w:.,_ ,..,,. ._......,,.... „ 18. Amount of Line 14 taxable !. at collateral rate X.15 �8 . ' _ __�.... _. _.,,, ..�...... .. . (� � . � 19. TAX DUE . . . .. . . . . .. ... .L.'. �... . .�..�.... ... .. ... . .. . .. .... . .. .. .. 19 � I � � _ _ __ _ _�� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Side 2 L 1505610205 1505610205 ,J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME �� -�---- -- - - -= - STREETADDRESS � ��—� _ __-�-z (�- �'L1��? _ _-------- __ ---- ---- - ��b�� _ CITY . _ __ STATE �� ZIP _ C�oS� Tax Payments and Credits: � l� � � � '. Tax Due(°age 2,Line?9) {1) ° 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} ✓ � � 7 3 � Make check payable to: REGISTER OF WILLS, AGENT. , �� . �� , ��z .�� , �»� �t � ��r��s � . � ,•� .:'.... ,xr��.c�� , ,..,..;, ...:a��\�£..6�� - ��il�,�, . . �»t,',�. ... ...� ��...,ict� . .. ..... ..�.�.....�...�. � �a�.r�. ..rac�.- ..,.�'�. . ..�.. ,i :�., . ...�.�•��.. ..3x 4"A'... ., ..... ... .. .......: , o av.r...... . . .. . . .. - PLEASE ANSWER THE FOLLOWING QUESTI�NS �Y 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 ............................................ ❑ 0 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 conteins a beneficiary designation? ....................... ❑ � ................................................................................................. iF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST C4MPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ..,., :� Z ., - ' z ' ? �'-- : ^t' .Y �:2 �1 i� "$�.4t � lt3h r � . . . , �;.; �,��.., r.,�+>,2• i,��r�.,. �,:, „ �,t��j„�', ..�Z,.fi�.�,,,,_,�v„ w,s»;;,_: �� ..',,. �aa�`� u��l'�,n.,�,., s�RS%„�fY�y„ , ��?��., .;�i'„:,. ��'r ,I.K°,•:'�',+a.., c�,�.�,:;.. . � ... . � j . . . For dates of death on or after July 1, 1994,antl 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 survivirig spouse from tax,and the statutory requirements for discfosure 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 chiid 21 years of age or younger at tleath 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 decedenYs lineal beneficiaries is 4.5 percent,except as notetl in[72 P.S.§9116(a)(1)]. . The tax rate impased 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 intlividual who has at least one parent in common with the decedent,whether by blood or adoption.