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Home My WebLink About12-29-14 J 1505611Z01 REV-1500 EX(oz-u) ; � ;+' OFFICIAL USE ONLY ii7 PA Department of Revenue pennsy(vania __ Bureau of Individual Taxes °"'p'ME"�°"`°`"°` County Code Year File Number Po Box zso6ol INHERiTANCE TAX RETURN Harrisburg,PA i�128-o6oi _ RESIDENT DECEDENT '�' � � � � I -lj� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death A4MDDYYYY Date of Birth MMDDYYYY �4a � � Suffix DecedenYs Firs t Name MI ''� ` �' �- �^'�- �t � +e. Y 5' (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 Retum � 2. Supplemental Return � 3. Remainder Retum(Date of Death Prior to 12-13-82) � 4. Limited Estate � 4a. Future Interest Compromise(date of d�.7 5. Federal Estate Tax Return Reyuired death after 12-12-82) L� 6. Decedent Died Testate p 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) C� 9. Litigation Proceeds Received C> 10. Spousal Poverty Credit(Date of Death � 11. Election to Tax under Sec.9113(A) � �g��_ 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 Telephone Number � o Y �E p 4'� o C KE N S �u ► �r H �t � � � '?� 3 � a '7 , ------�----.---�--.� � �`cisTFR or--v�Ls�rn��.r ! � � � � C�? Q � First Line ofAddress � c� �;y %°� C"�`1 � � i � �� =T3 ,�, t'-_ fV t;8 f"+"1 3 8 5 � r a � D � 12v� �1 �,� j �M„. � � � � �.� Second Line ofAddress � ` lx� =f� "� �� , q � r.� —� � —s'.' I i , .:r.r � ""�"I � .� � �' C'� I _ City or Post Office State ZIP Code �—,— -l..-dfi`r�1�Fa��'� ; . 1 :) .-�� Cn �3e.....___ � � v� v > > E �� -� � � � .,.. � � �� r, ��. k. t,.,�a....�..�,...�� ,�•� CorrespondenYs e-mail 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 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. SIGNAT OF PERSON S NSIBLE F R FILI G RETURN � � 0. �� DATE �y-M� �� ADDRESS `�." �\��_.o,_,__ �.�.�...�___.��._.. NOV ' /. ��u- 4A�" �r...� r -�.--� - ._� .��"7a�.�.�_�__..._..____,___�.- SIGNATURE O PREPARER O ER THAN REPRESENTATI DATE �"��. ADDRESS.-...�.�.�..._.�...�..,...�..��._�.�.�.A_.�._. _�...,.... --� — - ----e — __. �� PLEASE USE ORIGINAL FORM ONLY ~��M�� 'w��M Side 1 L 1505611101 1505611101 J h�� 1505611201 REV-1500 EX DecedenYs Social Security Number DecedenYs Name: �� `� � � _, __..__�.�._____.___..__.__.__..._._. .__.____._, RECAPITULATION 1. Real Estate(Schedule A). . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. • l� 2. Stocks and Bonds(Schedule B) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. • Q 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. • V 4. Mortgages and Notes Receivable(Schedule D) . . . .. . . . . . . . . . . . . . . . . . . . . . . 4. • O 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . . . 5. • y 6. Jointly Owned Property(Schedule F) fi�� Separate Billing Requested . . . . . . . 6. • 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) �"'� Separate Billing Requested.. . . . . . . 7. • 8. Total Gross Assets total Lines 1 throu h 7 $� ' � g ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . _..__._...._ _.__ .. _�..._,..__ _._.__.__._ .. _. .. ___ . _. _ __.__...__ .�_.._..._..._ ..�.. ._ 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . . . . . . . 9. • � 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . . .. . . . . . . . . . 10. • Q 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. • 4 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. ' Q. 13. Charitabie and Governmental Bequests/Sec 9113 Trusts for which � an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. • 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. • .:.,.�.�_._...�..::..___,,�.�.�.,.,..�.��..�,a,.��...ed..__._ _-_,.,__,a.�_. _ . �_..._�___.__.....�...�.,.�.,...a�._.�....�..�.,,�.. TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 �a)�1.2)X.0_ . 15. , • 16. Amount of Line 14 taxable at lineal rate X.0_ • 16. • 17. Amount of Line 14 taxable at sibling rate X .12 ' �� 18. Amount of Line 14 taxable at collateral rate X.15 ' �$ � 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . 19. • 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Side 2 � 1505611201 1505611201 � REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME � ---------`�n�-- , . STREETADDRESS �—��—--— ---—_—__ ___—___—__ =fA . _ _ _ _ _ _ __ __ _ —___-- -- -- JL.BI.• 1__�ac-�.�-t.�, _ �o -- ----_ �__ -- ____ -�-__ ___- ---------_____ ---____---------—---- CITY , - ------- _-- ---- ------ I STATE — _.___. . ZIP ---- �a � �� a�rr Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 2. Credits/Payments �� 0 A.Prior Payments ------—-- B.Discount - . 3. Interest Total Credits(A+g� (2� D 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. �3� 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) 0 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 transferretl ........................................... .................................... . 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 tlecedent transfer property within one year of death without receiving adequate consideration?...................... � ........ ..... .... ...... ....... .. ........................................................ 3. Ditl decetlent 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 imposetl 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)j. • The tax rate imposetl 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 decedenYs siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined, untler Section 9102, as an individual who has at least one parent in common with the decedent,whether by biood or adoption. , �� _ � �� < �� (�' _ � �' � � �, RECG�� -�,;� �F _ � � ;� � � Ft E G�"-��: �,�- ,,''��.L S —� u � '�14 DEC 24 �� i 2 �+9 .- � �. V `� � � i CL�C.�� ; . GR'HAh'S' �C� ..� �= � � CtJ��_�! "�' ''��t� � , � �, , � , _ � � ', � � , �� ,: _ � G " r `' , � �.�..� '�. s. ' 4 i ��, � � � � ,�,�,� � �