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Home My WebLink About07-08-14 � 1505611101 REV-1500 EX��_��> �� PA Department of Revenue pennsylvania OFFICIAL USE ONLY � Bureau of Individual Taxes �"AprM`�'� County Code Year File Number Po Box 28o6oi pINHERITANCE TAX RETURN � / / � � � � Harrisburg,PA i�128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � 3c� �f�.° r � a � o � � � DecedenYs Last Name Suffix DecedenYs First Name MI � � �rS �Q,n C, � (If AppRcable)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 �p 1. Original Return p 2.Supplemental Return �? 3. Remainder Return(Date of Death Prior to 12-13-82) � 4. Limited Estate p 4a. Future Interest Compromise(date of � 5. Federal Estate Tax Return Required , death after 12-12-82) O 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 7 O 9. Litigation Pro eeds Rec ived p 10.Spousal Poverty Credit ate of Death O 11. Election to Tax under Sec.9113(A) �S-M,-¢-� ,,,� Be r� 31 d � �c��e�)�____.�....,�_._.� ��n�.�� .s� CORRESPONDENT- THIS ECTION MUST BE COMPLETED.ALL ORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION OULD BE DIRECTEQ T0: Name Daytime Telephone Number i �- � e S e. a � Q e� a�- '1 I '7 � Cv �� -�-- � FtE:�ISTE �UiLLS US�,ONI_Y — ��T'�� C� � �j��_ �'�— r' f.J I �—�—�.'-- e r_ :T„j First Line of Address � �=a' � � -; '� �' f �cr, t�p , `;, a a S l� �. p l� e�r d � o a c� �� = -� - �� Second Line of Address � - � � _`-r' � � �� City or Post Office State ZIP Code _� oA7�FlLEt�� A_ � �w� , 11 � p (�- 1 � a � 1 Correspondent's e-mai�address: ��t„(�,,,�q P� i-Jr"(�,� , (��'. (`�{y� Under penalties of perjury,I declare that I have examined t ' 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. SI ATURE OF PERS N ESPONSIBLE FOR FILING RETURN � DATE � �.� � .�_. �an.g._,�`��-( �a _ �� a� _�____.�. SIGNATURE O PREPARER OTHER THAN REPRESENTATIV� � DATE � ADDRESS �� PLEASE USE ORIGINAL FORM ONLY � � Side 1 � 1505611101 15�5611101 J � . � 1505611201 REV-1500 EX DecedenYs Social Security Number DecedenYs 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. • l�j�j (,�l�tJ 4. Mortgages and Notes Receivable(Schedule D) . . . . .. . . . . . . . . . . . . . .. . . . . . . 4. • l)-'`�- `",� c 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. . . . 5. • � i"'�` ,Q� 6. Jointly Owned Property(Schedule F) � Separate Billing Requested . . . . . .. 6. • �l 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) f�+ Separate Billing Requested.. . . . .. . 7. . 8. Total Gross Assets(total Lines 1 through 7). .. . . . .. . . . . . .. . . . .. . .. .. . . . . 8. . 9. Funeral 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. . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . .. . . . . 13. . 14. Net Vaiue 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 A_ . 15. . 16. Amount of Line 14 taxable at lineal rate X.0_ . 16. . 17. Amount of Line 14 taxable at sibling rate X.12 • �7. • 18. Amount of Line 14 taxable ' at collateral rate X.15 • 18• • 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 19. . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 � 1505611201 1505611201 J ` REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME --� , _ l� __ - -- -- STREETADDRESS aa S�d CITY - — --- -- —- - _ STATE ZIP � � �- �- a y I 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. . M..�e�� . �'�ft'�''��o«�G'ri16��Ii�,e�r��(��'4_�� " �!� ��-, " rzs r?'� �.,� "'rlh�t�d�i F � r��9id�,="�: . �-�n1„t� =-s'^�^.A h �"= r4 a��'nr� . .. 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 tlesignate 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 consitleration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 4. Did decetlent 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. �w, _ . �� _ �� > ..�r_� ��. ,. , , �� a : r.,� s�� _ 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 tleath 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 decedenYs lineal beneficiaries is 4.5 percent,except as notetl in[72 P.S.§9116(a)(1)]. . The tax rate imposed on the net value of transfers to or for the use of the decetlenYs siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is tlefined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1502 EX+ (01-10) � � pennsylvania SCHEDULE A DEPARTMENT OF REVENUE � INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been"sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION i. e�� C�l o�o� cj��' ��(y� � �� `�� .,n � ,�� , ��..�.� �� - ---��.�.�. �. ��-�-- � � � � r .� � � . � . �-�� TOTAL (Also enter on Line 1, Recapitulation.) $ If more space is needed, use additional sheets of paper of the same size. REV-1503 EX+(6-98) ` SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) _._._ _ . _ _ _ REV-1504EX+(1-97) SCNEDULE C em � CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYIVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent,other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 3, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) _. _ . _ _ _ . _ _ REV-1505 EX+(6-98) � � SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorpor n Address Date of Inco oration City State Zip Code Total N ber of Shareholders 2. Federal Employer I.D. Number Bu ' ess Reporting Year 3. Type of Business ProducUServic 4' TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting/Non•Voting SHARES OUTSTANQING PAR 4ALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictio pretaining to each class of stock. 5. Was the decedent employed by the Corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, Position Annu alary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 7. Was there life insurance payable to the corporatio upon the death of the decedent? . . . . . ❑Yes ❑ No If yes, Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. Did the decedent sell or transfer an stock i this company within one year prior to death or within two years if the date of death was prior to 12-31-82 ❑Yes ❑ No If yes, ❑T nsfer ❑ Sale Number of Shares Transferee or Purchaser Consideration$ Date Attach a separate sheet for additio I transfers and/or sales. 9. Was there a written shareholder's reement in effect at the time of the decedenYs death? .. ..❑Yes ❑ No If yes, provide a copy of the agr ement. 10. Was the decedenYs stock sold ........... . ......... . . . ............ . ....... . . ....... ❑Yes ❑ No If yes,provide a copy of the reement of sale,etc. 11. Was the corporation dissol d or liquidated after the decedenYs death? . . . ........ . ..... ... ❑Yes ❑ No If yes,provide a breakdo of distributions received by the estate, including dates and amounts received. 12.Did the corporation h e an interest in other corporations or partnerships? . . . . . . . . . . . . . ❑Yes ❑ No If yes, report the nec ssary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • • - • � � A. Detailed calculations used in the valuation of the decedenYs stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns(Form 1120)for the year of death and 4 preceding years. C. If the corporation owned real estate,submit a list showing the complete address/es and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. List of principal stockholders at the date of death,number of shares held and their relationship to the decedent. E. List of officers,their salaries,bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedenYs stock. (If more space is needed,insert additional sheets of the same size) ��. e REV-1506 EX+(9-00) . SCHEDULE C-Z COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Com nced Address Business Repo ' g Year Ciry State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ❑ General ❑ Limited partner. If decedent was a limited partne provide initial investment$ 5 i� �'� i��,��. :.. � . ';��:��—�. � �i��'�3� ' .. ,rr :, � ��:;��.. ,.,�..,; ._ . .:; ,�s�:�:;�,,� �;; -��. :�k;�sH_ �.._ .. a�:.�.._. � �:�;�� . ;�:�,��}.s�: A. B. C. D. 6. Value of the decedenYs interest$ 7. Was the Partnership indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 8. Was there life insurance payable to the partner ip upon the death of the decedent? . . . . . ❑Yes ❑ No If yes, Cash Surrender Value$ Net proceeds payable$ Owner of the policy 9. Did the decedent sell or transfer an int est in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ❑Yes ❑ No If yes, Transfer ❑ Sale Percentage transferred/sold Transferee or Purchaser Consideration$ Date Attach a separate sheet for ad tional transfers and/or sales. 10. Was there a written partners ' agreement in effect at the time of the decedenYs death? . . . . . . ❑Yes ❑ No If yes, provide a copy of t agreement. 11. Was the decedenYs pa ership interest sold? . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . ❑Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 12.Was the partnership dissolved or liquidated after the decedenYs death? . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 13.Was the decedent related to any of the partners? . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes,explain 14.Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . . . ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • � • - � • � . A. Detailed calculations used in the valuation of the decedenYs partnership interest. B. Complete copies of financial statements or Federal PaRnership Income Tax returns(Form 1065)for the year of death and 4 preceding years. C. If the partnership owned real estate,submit a list showing the complete address/es and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. Any other information relating to the valuation of the decedenYs partnership interest. REV-1507 EX+(1-97) _ � SCFIEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-i5o8 EX+(ii-io) � pennsyLvania SCFIEDULE E � DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on Line 5, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. REV-15og EX+(oi-io) � � pennsylvania SCNEDIJLE F DEPARTMENT Of FEVENUE INHERITANCE TAX REfURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING]OINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. C. 70INTLY OWNED PROPERTY: LETTER DATE DE RIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIA NSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE Of DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUM .ATfACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL(Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. . �► REV-1510 EX+ (08-09) � pennsylvania SCHEDULE G DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH %Of DECD�S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. TOTAL(Also enter on Line 7, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND - INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1 FUNERAL EXPENSES: �(:J'�-'� �� `� �I)V—�� C B, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: _� Name(s)of Personal Representative(s)_f ��.,1 C.,,1�'CfO�- � ,�z�'-Y Street Address ��_� ��' City 1 State�ZIP j��1 Year(s)Commission Pai� I� , ! r ' � ,S C.�(�� , 2. Attorney Fees: �'� `�w �� 1�"' � 3. Family Exemption; (If decedenYs address is not the same as claimanYs,attach explanation.) Claimant Street Address City State ZIP _ Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fee , 7. TOTAL(Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) � pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF 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. TOTAL(Also enter on Line 10, Recapitulation) $ If more space is needed,insert additional sheets of the same size. REV-1513 EX+ (O1-10) � pennsytvania SCHEDULE � DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIPTO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. 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. REV-1514EX+(12-03) SCNEDULE K � LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single life,joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ❑ Will ❑ Intervivos Deed of Trust ❑ Other • NAME(S)OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM ffF YEARS DATE OF DEATH IIFE ESTATE IS PAYABLE ❑ Life or ❑Term of Years Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interest table rate—❑ 3 1/2% ❑ 6% ❑ 10% ❑Variable Rate °/a 3. Value of life estate(Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ • NAME(S)OF LIFE ANNllITANT(S) �ATE OF BIRTH NEAREST AGE AF ' TERM Of YEARS bATE OF DEp?H ANNUITY IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which annuiry is pa able . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below an enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . . Frequency of payout—❑ Weekly(52) ❑ Bi-weekly(26) ❑ Monthly(12) ❑ Quarterly(4) ❑ Semi-annually(2) ❑ Annually(1) ❑ Other( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Annuity Factor(see instructions) Interest table rate—� 3 1/2% ❑6% ❑ 10°/a ❑ Variable Rate % 6. Adjustment Factor(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity— If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period,calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ NOTE:The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return.The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size) REV-1644 EX+ (01-10) � � P@1111S�/�Va111a INHERITANCE TAX DEPARTMENT OF REVENUE SC H E DU LE L - INHERITANCETAXRETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST CORPUS I. ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents dying on or before Dec. 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) of Efection or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . .$ 3. Closely Held Stock/Partnership . . . . . . . . . . . . .$ 4. Mortgages and Notes . . . . . . . . . . . . . . . . . . . .$ 5. Cash/Misc. Personal Property . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . .$ 2. Unpaid Bequests . . . . . . . . . . . . . . . . . . . . . . .$ 3. Value of Non Includable Assets . . . . . . . . . . . . .$ 4. Total from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . .$ F. RemainderFactor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G. Taxable Remainder Value (Multiply Line E by Line F) . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Remainder Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) , REV-1645 EX+ (11-09) ?]!� peC111Sy�Val118 INHERITANCE TAX «,� DEFARTMENTOPREVENUE SCHEDULE L�1 INHERITANCETAXRETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -ASSETS- I. ESTATE OF FILE NUMBER II. ITEM N0. DESCRIPTION VALUE A. Real Estate (Please describe.) Total Value of Real Estate $ (Include on Section II, Line C-1 on Schedule L.) B. Stocks and Bonds (Please list.) Total Value of Stocks and Bonds $ (Include on Section II, Line C-Z on Schedule L.) C. Closely Held Stock/Partnership - Please list. (Attach Schedule C-1 and/or C-2.) Total Value of Closely Held/Partnership $ (Inciude on Section II, Line C-3 on Schedule L.) D. Mortgages and Notes (Plea e list.) � �� ) �� Total Value of Mortgages and Notes $ (Include on Section II, Line C-4 on Schedule L.) E. Cash and Miscellaneous Personal Property (Please list.) Total Value of Cash/Miscellaneous Personal Property � (Include on Section II, Line C-5 on Schedule L.) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L.) � If more space is needed, attach additional sheets of paper of the same size. __ _._ REV-1646 EX+ (11-09) . ' ''pennsylvania lNHERITANCE TAX �y� DEPARTMENTOFREVENUE SCHEDULE L�� irvHeRlTaruceTaxRETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- I. ESTATE OF FILE NUMBER II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Liabilities $ (include on Section II, Line D on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Sc dule L-1 (please list) T tal Unpaid Bequests $ include on Section II, Line D-2 on Schedule L) C. Value oF Assets Reported n Schedule L-1 (other than unpaid bequests listed under"B" above) that a Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows� Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV-1647 EX+ (02-10) � �'i`� pennsylvania SCHEDULE M �� DEPARTMENT OF REVENUE FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on REV-15oo) ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach.a copy to the tax return. ❑ Will ❑ Trust ❑ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ❑ Unlimited right of withdrawal ❑ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) . . . . . . . . $ 3. Value of Line 1 passing to spouse at appropriate tax rate � Check one. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) . . . . . . . . $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . $ If more space is needed, use additional sheets of paper of the same size. _ _ _ _ _ _ _ REV-1649 EX+(OS-09) � � pennsylvania SCNEDULE O DEPARTMENT OFREVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC.2ii3(A) RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 2113(A) of the Inheritance and Estate Tax Act. If the election to more than one trust or similar arrangement,a separate form must be filed for each trust. This election applies to the Trust(marital, residual A, B,by-pass, Uni�ed Credit,etc.). If a trust or similar arrangement meets the requirements of Section 2113(A)and: a.The trust or similar arrangement is listed on Schedufe 0 and b.The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,then the transferor's personal representa- tive may specifically identify the trust(all or a fractional portion or percentage)to be included in the election to have such trust or similar proper- ty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0,the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0.The denomi- nator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 2113(A) trust or similar arrangement. Description Value Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 2113(A) election to tax is being made. Description Value Part B Total $ If more space is needed, use additional sheets of paper of the same size. :� .� :.=,. .� .� ::.`� ��. :.�.,, � ;� n C� � c`�i � —�n —n °oc �; �m 0 o a'�' o �m � m'^ `:.. '.,;. � � o � w � . � ,; � � z � m c ' c f • o� 3r-�� o Oo�1rD 00~� C�INr�� m. z- dmoo cNn� � . . � — v � oN � � � � � o m �