HomeMy WebLinkAbout08-01-14 (2) 1505611101
REV-1500 EX(az-"' ' '
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of individual Taxes County Code Year File Number
PO BOX 280601
INHERITANCE TAX RETURN
Harrisburg,PA 17128-06ai RESIDENT DECEDENT .' `# % `J, ._l.._.E.`t',L.J�:.).
ENTER DECEDENT INFORMATION BELOW
Social Security Number _ Date of Death MMDDYYYY Dale of Birth MMDDYYYY
_!0J5101�.
Decedent's Last Name Suffix Decedent's First Name MI
• - -+ter �-. .:y���-..± 'y���� �/1�
A t' LT --
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name yyFF yytt MI
{` I rte+ 1Y� 1.�� .
Spouse's Social Security Number wi+ .=!
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
Jj_ _.� 1jj 3 REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
B 1.Original Return O 2.Supplemental Return p 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a,Future interest Compromise(date of p 5. Federal Estate Tax Return Required
death after 12-12-82)
® 6. Decedent Died Testate C=D 7, Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Tmst_)
O 9,Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 1231-91 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
REGISTER OF WILLS USE-DNLY T,
C p
First Line ofAddress �y = `ziv�- � r• Cti
_ f
rri
Itt �s r IP14 j '' r
Second Line of Address rJ `- T
City or Post Ofiir i -State ZIP Code -FILED >—}�
` `++iF .m>.+. a... N
rilt + a�w)twi �. !_ �! PjW7 l 7 4 5� � r
11�'� 11 i
Correspondent's e-mail address: T\ 4 A-D 1v, 4A 0_0 w C A t h f
Under penalties of perjury,I declare that 1 have examined this 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 knuMedge,
SIGNA,TU OF PERSON R�SPON$IBLE F.OR FJt)NG RETURN DATE
C IP+ !/tl �yt '7b 31 Z�
ADDRESS t / 1 T_ Z
t�°Ar`r. ' Q� 112rlsr �1,�rJ MJ 1-fla :t�:. r t 17,57
SIGNATURE OF PREPARER OTHER Ti4AN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611101 1505611101
1505611201
REV-1500 EX Decedents Social Security Number
Decedent's Name: Ma r
RECAPITULATION
1. Real Estate(Schedule A). ........ ............_1.....
917
2. Stocks and Bonds(Schedule 8) ................... 2. 3 1_0
T'l
Elf o
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. i
CA4. Mortgages and Notes Receivable(Schedule D) 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. J -6
6. Jointly Owned Property(Schedule F) =Separate Billing Requested 6..
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property A
(Schedule G) Separate Billing Requested........ 7.
11 f I>1 W_71 �!�L
Ali8. Total Gross Assets(total Lines 1 through 7). ...... 8 A wdla!'91 L7._
k 1451
9. Funeral Expenses and Administrative Costs(Schedule H), .... .....__ 9. JJ_WAC)" 11,5.".L
TV J- 1
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). ....... 10. J
11. Total Deductions(total Lines 9 and 10).... ...... if. J.
12. Net Value of Estate(Line 8 minus Line 11).. ... .... . . . .... . .. .... .... 12. 0
AJ I J-1 I Ai
13. Charitable and Governmental BequesWSec 9113 Trusts for which ---I - -
an election to tax has not been made(Schedule J) . .. . .... .... ... . ... ... . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ... .... . 14. -
TLt Ih � ()UP"'LjlpL gz
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
I'll L 4 .1 1 _J
16. Amount of Line 14 taxable t
ri 71 T
at lineal rate X.0,HS t L 16.
17. Amount of Line 14 taxable
-I - -
'at sibling rate X.12 17.
18- Amount of Line 14 taxable Ji
at collateral rate X.15 :By -1 , I IT,
19. TAX DUE , ... .. .. .. . . ... .. . ... . .. ia
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505611201 1505611201
REV-1500 E'X.Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
M Amoy �l G-R6r e
STREETADDRESS
3_,15 WesIe7 L) r-. Iii, 3311 _
CITY STAT ZIP
0\ CC kCLV6,es b moss
Tax Payments and Credits: g
1. Tax Due(Page 2,Line 19) (1) y 83 '
2. Credits/Payments
A.Prior Payments 0
B.Discount _ o5_a-r�3 f8
Total Credits(A+B) (2) y
3. Interest
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)
(� L$
5. If line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 7
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 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)(it)].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 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-1502 EX+ (01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MAr4 M GAS --, e, 1
All real property o ned 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
1.
C) r,
TOTAL (Also enter on Line 1, Recapitulation.) $ Q
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.
JLICC+ Ass( ,+ v cx, QcJ' Cvr.c tl�a
It
3 F rn�t�nr Fl�a+; 5 Ra1c C ti &o
°- '!`I� o• g a v- 54 o c4 eel%c Tnc vmC
v r S r F!o-n4.•vj R cl-r
Pr t— C i,36s „
a-�
J _ �y ! q� c�
Tr k s +
gz
3 ptvC i .. ,el5+ rw+ S 30-J Pr-4 — Iolo�S
+
Lnlctss
t3lack
TOTAL(Also enter on line 2, Recapitulation) $ 193 p q 1 57
(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
I. Name of Corporation State on Incorporation
Address Date of Incorporation
City State_Zip Code Total Number of Shareholders
2. Federal Employer I.D.Number Business Reporting Year
3. Type of Business Product/Service
4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK yotingMon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
a
Common $
Preferred $
Provide all rights and restrictions pretaining to each class of stock.
5. Was the decedent employed by the Corporation? ..... ... ..... . .. ...... ..... . ..... ❑Yes ❑ No
If yes, Position Annual Salary $ Time Devoted to Business
8, Was the Corporation indebted to the decedent? . ................. . ...... . . ..... . . . O Yes ❑No
If yes,provide amount of indebtedness$
7. Was there life insurance payable to the corporation upon the death of the decedent? .... . Q Yes 0 No
If yes,Cash Surrender Value$ Net proceeds payable$
Owner of the policy
8. Did the decedent sell or transfer an stock in 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, ❑Transfer ❑Sale Number of Shares
Transferee or Purchaser Consideration$ Date
Attach a separate sheet for additional transfers and/or sales.
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....Cl Yes ❑ No
If yes,provide a copy of the agreement.
14.Was the decedem's stock sold? ..................................................... ❑Yes ❑No
If yes,provide a copy of the agreement of sale,etc.
1 f. Was the corporation dissolved or liquidated after the decedent's death? .................... 0 Yes 0 No
If yes,provide a breakdown of distributions received by the estate,including dates and amounts received.
12.Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . . ❑Yes ❑ No
H yes, report the necessary information on a separate sheet,including a Schedule C-1 or C-2 for each interest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax returns(Form 1120)for the year of death and d preceding years.
C. If the corporation owned real estate,submit a list showing the complete addreWes 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. ,
O. Any other information relating to the valuation of the decedent's stock.
(it more space is needed,insert additional sheets of the same size)'
7y yf�h 1
REV-1506 EX+(9-00) SCHEDULE C-2
COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP
INHERITANCE TAX RETURN
RESIDENT DECEDENT INFORMATION REPORT
ESTATE OF FILE NUMBER
1. Name of Partnership Date Business Commenced
Address - Business Reporting Year
City_ - State Zip Code
2. Federal Employer I.D.Number
3. Type of Business - Product/Service
4. Decedent was a d General Q Limited partner. If decedent was a limited partner,provide initial investment$
5. PARTNER NAME PERCENT PERCENT BALANCE OF
OF INCOME OF OWNERSHIP CAPITAL ACCOUNT
A.
B.
C.
D.
6. Value of the decedent's interest$
7. Was the Partnership indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . ❑Yes Q No
If yes,provide amount of indebtedness$
8. Was there life insurance payable to the partnership upon the death of the decedent? .. . . . d Yes ❑ No
If yes,Cash Surrender Value$_ - Net proceeds payable$_
Owner of the policy
9. Did the decedent sell or transfer an interest 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 additional transfers and/or sales.
10.Was there a written partnership agreement in effect at the time of the decedent's death? . . .... ❑ Yes ❑ No
If yes, provide a copy of the agreement.
11. Was the decedent's partnership interest sold? ....................................... ❑Yes ❑ No
If yes,provide a copy of the agreement of sate,etc.
12.Was the partnership dissolved or liquidated after the decedent's 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? .............. Q Yes ❑ No
If yes, report the necessary information on a separate sheet,including a Schedule C-1 or C-2 for each interest.
THE FOLLOWING INFORMATION
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership 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 addressies 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 decedent's partnership interest.
• REV-1507 EXa(1-97) N ►
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
ITEM All property jointly-owned with right of survivorship must be disclosed on Schedule F.
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
7V . e
TOTAL(Also enter on line 4, Recapitulation) $
(If more space is needed,insert additional sheets of the same size)
IEV-1508 EX+(ii-1o)
Z' pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE CED RETURN PERSONAL PROPERTY
ESTATE OF:
A r- t 1\ A b ' FILE NUMBER:
Include the proceeds of litigation and the date the proceeds were received by the estate.
ITEM All property jointly owned with right of survivorship must be disclosed on Schedule F.
NUMBER DESCRIPTION VALUE AT DATE
N n p OF DEATH
14 � o
TOTAL (Also enter on Line 5, Recapitulation) $
If more space is needed, use additional sheets of paper of the same size.
• AEV-a5o4 EX+(o-io)
i i pennsytvania - SCHEDULE F
V \\' DEPARTMENT OF REVENUE
®e . JOINTLY-OWNED PROPERTY
INHERTANCETAXRETURN
RESIDENT DECEDENT `
ESTATE OF: / 1 FILE NUMBER:
i ' YCiry �T T�,. tT'A-pf�P , �
If an asset t became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVMV G JOINT TENANT(S),NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. tTaFi J �Tf�� r: C' � F350 ` C✓ A*,lr;a9C �ousr � $ 4
- (Y\`•clp-i, ic-t;ow ..t G'a � 7os7
g' .Lptc� wOn. $icw•ic!,L.. .�".VPrvTCw �� ("
Le w.uy nr 1 �a 1? 04 3
C
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY 11,OF DATE OF DEATH
ITEM FOR IOI.NT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINT IDENTIFYING'NUMBER.ATTACH DEED FOR JOINTLY MELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
t. A. oat�o�g POCr �a.r.k� ia$�a7f tY E'Ra
a*i ai\ec�;, � . qd 0049 'J83d -71 (e . 33`10
5g
sav �qs - 4d 8503 yg0a irl9d $.—
t71
3i
- - TOTAL (Also enter an lane 6, Recapitulation) $' — (�
If more space is needed,use additional sheets of paper of the same size. ,
If more space is needed,use additional sheets Of paper of the same size,
1
REV-1511 EX+ (10-09)
pennsylvania SCHEDULE H
DEPARTMENT NCETAX REVENUE FUNERAL EXPENSES AND
INHERITANCE CE ED RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF
y FILE NUMBER
ITEM
Decedent's debts must be reported on Schedule I.
NUMBER - DESCRIPTION
A. 1. FUNERAL EXPENSES: AMOUNT
_ Re, Fuhetal No,11wc- (Servzcc) o0
I {� 1 / 4� p00
C.CQ¢r 14�, ( Mew t"qr K `13tAr;a�) rf ..5 3 d
B. ADMINISTRATIVE COSTS:
1• Personal Representative Commissions: //�� f
Name(s)of Personal-Representative(s) A (PcN a Lr- �r C a 0
Street Address (3 50 C rr J O O
Arr'a-aa Wo..cS (�
yyvy�� J n
City State V"
_ZIP 1-70!;,7
Year(s)Commission Paid:_aC?t_!L
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:
S• Accountant Fees:
6. Tax Return Preparer Fees:
7. Fee S oa
0 —
I/
Pr;cs+ Tee a+ �kr:a� ` U (gb0
C75 + 14u� 00 —
o
cww.. C (des bF w-. lls a3-6
3g35r,is
TOTAL (Also enter on Line 9, Recapitulation) $ � 5 5
If more space is needed, use additional sheets of paper of the same size.
• LREV-1512 EX+(12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT'
ESTATE OF f� FILE NUMBER
MP`tiF �{��S"'.
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+ (01-10)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF:
G- (k r; e FILE NUMBER:
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Do Not List Trustee(s) OF ESTATE
Sec. 9116(a) (1.2).]
1.
AAA-ry T G-A-6I—e I
13350 Ca ':0,3e (+O Lit SC � . Sor 5 o7.
e40wr` V 4 rTU$7
LUrs � o,ts � e-wieZ
81S dak
lZ:vrr � ,r Rd gl�+cr o7o
Le mO� h P I 1 a 17D43
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. O