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HomeMy WebLinkAbout07-17-14 (3) 1505611101 REV-1500 EX(M-11) f PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes ° INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 Harrisburg,PA 27128-0601 RESIDENT DECEDENT O � � ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY �:71 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 Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1.Original Return C= 2.Supplemental Return O 1 Remainder Return(Date of Death f Prior to 12-13-82) ' Q ^4.Limited Estate . Q 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 B. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received Q 10.Spousal Pdverty 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 QETU ?rNl hl MELD Li �77'9R-70 n . , REGISTER 9W .LS U$E 1§Yjj.Y J rn rnZ r - r U -c=1 First Line of Address "''' J 0 G .Lr. Second Line of Addrests, {i r DATE FILED City or Post Office State ZIP Code - Correspondent's e-mail address: Under penalties of perju are that I have examined this return.including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,cotreIX antl piete. amiion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF QtR N RES N$IBLE FOR FILING RETURN DATE god ADDRESS SIGNATUgg��OF P EPARER OTHER THAN R€PRESENTATIVE DATE l'7da i ADDRESS PLEASE USE ORIGINAL FORM ONLY ' Side 4 1505611101 1505611101 t 1505611201 REV-1500 EX Decedent's Name: RECAPITULATION yn, t� 1. Real Estate(Schedule A). ............................................ IL . , n/ . U • 0 tn� 2. Stocks and bonds(Schedule B) .. .......... .. . ....... .... ..... . ... .... 2. .,,, 2 7 i (' d • d 0 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. I1•0 40 4. Mortgages and Notes Receivable(Schedule D)......... .......... ........ 4. VjJ• U V 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. '!, 09 `f'• 9+J r 1 'ry }r 6. Jointly Owned Property(Schedule F) O y Separate Billing Requested ....... 6. . 0 D 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7, d /J L 8. Total Gross Assets(total Lines 1 through 7)........... .................. 8, f tp7T.f //j}} ✓ 7 , 9. Funeral Expenses and Administrative Costs(Schedule H).. ...... . . ... . .. 9. 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 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 BequeststSec 9113 Trusts for which -- -- - " ��1-t r-t an election to lax has not been made(Schedule J) . .... ... ... ... ... .... .. 13. tI r u 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_ 75. 16. Amount of Line 14 taxable at lineal rate X.0ttr�! 16. ) b 7 • 1L4 17. Amount of Line 14 taxable at sibling rate X .12 • 17. 18. Amount of Line 14 taxable v at collateral rate X.15 Y .. 18. /y . 19. TAX DUE . . .. . . . ... .. . ... ... . .. . ... .... ... .... ...... . ... ... . .. . ... 19. ,�. 1 F-' t[• `� 4 7 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505611201 1505611201 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME IyIl1QG #o47T S; cldlva STREETADDRESS I15 wkh�E y�2 11 &1 /G/ 199> 170fj�j CITY STATE ZIP Tax Payments and Credits: Q 1. Tax Due(Page 2,Line 19) (1) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) —0 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. 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.......................................................................................... ❑ Is b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ IN 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 [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 fling 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)(12)]. • 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+ (12-12) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN 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 TOTAL(Also enter on Line 1, Recapitulation.) $ O If more space is needed,use additional sheets of paper of the same size. REVa503 EXa(8a2) r pennsytvania SCHEDULE B DEPARTMENTOF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER AQG�f� T 5', c/DNkh ILI- 07-0/3 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 mEiX-/f� /�vv�hrn�h l���lirbb 7"110 vkv&11'v3 loQo/j/7 GvgdrDD i TOTAL(Also enter on Line 2, Recapitulation) $ �� ltltc/rOD If more space is needed,insert additional sheets of the same size REV-1504 EX+(1-97) ab SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER AM f S, c%h 2i — v7— 011 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. 0 TOTAL(Also enter on line 3, Recapitulation) $ X (If more space is needed,insert additional sheets of the same size) REV 1505 Ex3 (1.1-:11) Pennsylvania SCHEDULE C-1 DEPARTMENT OF REVENUE CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation _ State of Incorporation Address _ Date of Incorporation City ___ _ State_ZIP Code Total Number of Shareholders 2. Federal Employer ID Number Business Reporting Year 3. Type of Business—---- Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting/Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK 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 j 6. Was the corporation indebted to the decedent? . . . . .. . . . . . . . . ..... . . . . . . .. . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 7. Was there life insurance payable to the corporation upon the death of the decedent? . . . . . d Yes 0 No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. Did the decedent sell or transfer 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? O Yes O No If yes, ❑Transfer ❑ Sale Number of Shares Transferee or Purchaser i_ Consideration$ __ Date Attach a separate sheet for additional transfers andfor sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? . . ..❑Yes ❑ No If yes, provide a copy of the agreement. 10.Was the decedent's stock sold? . . . ........ . . ......... ...... ............ . . . . ..... . ... ❑ Yes ❑ No If yes, provide a copy of the agreement of sale,etc. 11. Was the corporation 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. 12. Did the corporation 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. THE FOLLOWING INFORMATION 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 four 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 relationships 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 decedent's stock. (If more space is needed,insert additional sheets of the same size.) 1W SCHEDULE C-2 COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFOWATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER I Name of Partnership Date Business Commenced Address Business Reporting Year city State_Zip Code 2 Federal Employer I.D.Number 3. Type of Business Producl/Service 4. Decedent was a El General E3 Limited partner. If decedent was a limited partner,provide initial investment 5. PERCENT PERCENT BALANCE OF :R NAME OF INCOME OF OWNERSHIP CAPITAL ACCOUNT A. B. C. G. Value of the decedent's interest$ 7, Was the Partnership indebted N the decedent? . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . O Yes []No . It yes,provide amount of indebtedness$ 8. Was there life insurance payable to the partnership upon the death of the decedent? . . . .. 0 Yes 0 No n yes,Cash Surrender Value Net proceeds payable $ Owner v,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 to12^31'82? 0 0s [] No If yes, OTrmofer OGa|e Pomentagetmndormd/m|d Transferee o,Purchaser ---___----_-' Consideration $ Date Attach n 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 [}Nn |f yes, provide a copy vf the agreement. 1t Was the decedents partnership interest sold? ....... ....... ........... []Yes []No K yes,provide n copy o[the agreement of sale,etc. 12. Was the partnership dissolved o,liquidated after the decedent's death? . . . .. . . . . . . . . O Yes ONo If yes,Pravda a breakdown of distributions received by the estate,including dates and amounts received, 13.Was the decedent related m any d the partners? . . . .. . .. . . .. . . . .. . . .. . . .. . . .. . . .. . O Yes []Nv |f yes, exp|ain 14,Did the partnership have an interest in other corporations or partnerships? ....... ...... []Yes [] No It 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, DeWed calculations used in the valuation of the decedenCs 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 address/es and estimated fair market xgue/s.|f real estate appraisals have been secured,attach copies. D� Any other information relating xo the valuation of the decedent's partnership interest. REV-1507 EX+(1-97) s SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER ? S, clollm 2/— 67—MIT All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH D TOTAL(Also enter on line 4, Recapitulation) $ Q (It more space is needed,insert additional sheets of the same size) REV-isoB EX+(u-io) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ln'94&444 r S. Lhw;6 2/-07 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 o94 g� TOTAL (Also enter on Line 5, Recapitulation) $ pq q If more space is needed, use additional sheets of paper of the same size. REV-i5o9 EX+(oi-io) U1NT pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN 30INTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ciav�h 2i- 07_ o��� If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ro OF DATE OF DEATH ITEM FOR]DINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSEr 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 DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RE5IDENT DECEDENT ESTATE OF FILE NUMBER 17941GINAr c%h 21- 07 — 01146' 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 % DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A CORVOFTHE DEED FORREAIESTATE. 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 DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER T Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: r i *D 4-o AUO/6-14 o,ba /ail T2rar1/ew- 01h1r4f1PY 20D,Da RpurNo G ZOAN 6Fr1;h7Z�y fipn,o0 ��11i1- /��00yre2i r ao.00 my�Q� -Al'iiI --Pvwi lhmh-MW4 444VG) %fib,oa C �✓ Ggr���N4 ��h',tia B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) - Street Address_ City State ZIP_ Year(s)Commission Paid: 2. 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: 6. - Tax Return Preparer Fees: 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) i 'pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 1n,g6dkr S, JOk�th zi- 07- '4145 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. 117A, (�9h1(v�iv��Qv/bGy C�oy�u�ro�r lr/,g AjVL- G'Qah7 — 19A, loa aw h 4*lwey 70/& AA-Fr/Ay ill"Iff 'm j/�•9i CL/NG lo 91 po low��1 �ucn/ �� �mr hravre�b /U�i�Db 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 J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO 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. I�uGH RAJ°Nrh 7oN s�i�n�iv,vo 2 /�1�16/ngrToX C�ouQt /17ECil�Ni @4/huQl�/ �//- /'Ieha fjD° (yeNEi//J �� Apf /I,1, ',7es5 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. fI 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 13 — 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-1514 EX+(4-09) pennsylvania SCHEDULE K DEPARTMENT OF REVENUE LIFE ESTATE,ANNUITY Bureau O Bwafx(io66of dual Taxes &TERM CERTAIN Harrlsburg PA 17u8-o6o1 (CHECK BOX 4 ON REV-15oo COVER SHEET) ESTATE OF FILE NUMBER This schedule should 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. 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 below the type of instrument that created the future interest and attach a copy of it to the tax return. ❑ Will ❑ Intervivos Deed of Trust ❑ Other LIFE ESTATE INTEREST CALCULATION NAME OF LIFE TENANT DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE 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 - ❑ 3.5% ❑ 6% ❑ 10% ❑Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ANNUITY INTEREST CALCULATION NAME OF LIFE ANNUITANT DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Tenn of Years ❑ Life or ❑Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and 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-❑ 3.5% ❑6% ❑ 10% ❑ Variable Rate 6. Adjustment Factor(See instructions.) . . . . . . . . . . . . . . . . . . . . . . . . .... . . . ... . . . . . . . . . . . . . . . . 7. Value of annuity-If using 3.5, 6,or 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 that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return.The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. if more space is needed, use additional sheets of the same size. REV-1647 Ex4(ot-la) pennsy(vania SCHEDULE M DEPARTMENT or REVENUE FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on REV-1500) 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 i. 2. 3. 4. S. 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 I 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 I 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 J taxable at lineal rate Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . I . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) S. Value of Une L taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line I 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) . . . . . . . . . . . . . . . . . . . . . . . $ It more space Is needed,use additional sheets of paper of the same size. REV-1649 EX+ (09-12) pennsylvania SCHEDULE O DEPARTMENT OF REVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC.2113(A) RESIDENT DECEDENT (SPOUSAL TRUSTS) ESTATE OF FILE NUMBER PART A - DEFERRING STATEMENT For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is being elected under Section 2113(a), the personal representative responsible for filing the return and the trustee(s) of the trust in question hereby acknowledge the department's Statement of Policy set forth at 61 Pa. Code § 94.3 concerning any potential termination of the trust under 20 Pa.C.S. § 7710.1 that occurs after the return was filed. Specifically, the signatories recognize each individual's assumption of liability for inheritance tax consequences that result from any termination of the trust under 20 Pa.C.S. § 7710.1 that occurs after a return has been filed. Signature of Person Responsible for Filing Return Signature(s) of Trustee(s) PART B – ELECTION TO TAX AMOUNTS Complete this section only if making the election to tax available under Section 2113(a) of the Inheritance & Estate Tax Act. If the election applies 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, unified credit, etc.). Enter the description and value of all interests for which the Section 2113(a) election is made. DESCRIPTION VALUE Total 1 — — If more space is needed, insert additional sheets of the same size.