HomeMy WebLinkAbout01-20-15 (2) � 15056141�5
� pennsylvania
oennarMErvroFacvErvuc EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Counry Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN � �' ' �°'
Po eox 2so601 RESIDENT DECEDENT
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW MMDDYYYY Date of Birth MMDDYYYY
Social Security Number Date of Death _ - --
;:123��miy f��2���12
�� _ _ MI
DecedenYs Last Name Suffix Decedent's First Name
_ _ C"JQ,� �
/JC1JINl�t'Y ......... .... ._.. ... __. ......_. .... ....... ....... ...... ...... _.._. _.... _..._ ......_ ._....
(If Applicable)Enter Surviving Spouse's Information Below Suffix Spouse's First Name MI
Spouse's Last Name _ __ _ _
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW 3. Remainder Return(date of death
� 1. Original Return p 2.Supplemental Return � prior to 12-13-82)
p 4.Agriculture Exemption(date of p 5. Future Interest Compromise(date of p 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
8.Decedent Maintained a Living Trust _ 9. Total Number of Safe Deposit Boxes
�q 7. Decedent Died Testate � Attach copy of trust.)
(Attach copy of will.) � 12. Deferral/Election of Spousal Trusts
� 10. Litigation Proceeds Received O 11. Non-Probate Transferee Return O
(Schedule F and G Assets Only)
O 13. Business Assets O 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Daytime Telephone Number
Name _ _
. ��7i�) Ff"a - 3�37
�}��P✓a�i rTcl<cre l�jc�l�H9�. _
First Line of Address _
!2 jl 2 .�'t�rn w�i`�' �i e yy C�- • '
Second Line of Address
State ZIP Code _
City or Post O�ce '
1 pp 1707 a
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CorrespondenYs email address: "`e n�'lZ v� �c�rcas�'• H�t
REGISTER OF WILLS USE ONLY
REGISTER OF WILLS USE ONLY J
dATE'FILED MMDDYYYY �=' '�
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PI.EASE USE ORIGINAI.FORM ONLY � c.�. � �-- �-n
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Side 1 -_� -`y� r-• u' -�i
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� 1505614205
REV-1500 EX(FI) DecedenYs Social Security Number
1�3 - 1v _ G3R�
DecedenYs Name:
RECAPITULATION
1.
1. RealEstate(Schedule A). . .. .... . . . . . . .. .. .. .. .. . . . . . . .. .. .. .. .. . . . .. _
2.
2. Stocks and Bonds(Schedule B) . .. .. . . . . . . . ... .. .. . . . . . . . . .... .. .. . . . . _ '
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 Personal Property(Schedule E)... . . . . 5. q, y 9 9 • U v
6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. . . . . . 6• „
7. Inter-Vivos Transfers 8�Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. . . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7). . . . . .. .. .. .. .. .
. . . .. . .. .. .. . 8. ' q 539 • ao
9. Funeral Expenses and Administrative Costs(Schedule H). ... ..
.. . . . . . . . .. . . 9. 3 037 . vo
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule i).. .. .. . .. .. ... . 10.
11. Total Deductions(total Lines 9 and 10).. . . . . . .. . . . .. .. . . . . . . . .. .. .. .. . .
11. ?, a35 • o0
. . . .. .. .. .. .. 12. („ �SbH • vu
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . .. . .. .. .. . . _
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which . 13.
an election to tax has not been made(Schedule J) . .. .. .. .... . .
14. Net Value Subject to Tax(Line 12 minus Line 13) . . .. .. .. .. .. . . . . . .. .. ... 14. ' � SEH • �� '
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or _ _
transfers under Sec.9116 ' 15. ', „ „ '
�a)�1.2)X .0- ' ' _. _ .
16. Amount of Line 14 taxable 16.
at lineal rate X.0� _ _ _ '
17. Amount of Line 14 taxable �� '
at sibling rate X.12 _ _ __ _
18. Amount of Line 14 taxable , �g
at collateral rate X.15
Zy� av
19. TAX DUE . .. . . . . . . . . .. .. .. . . . . . . . .. .. .. ... . . . . . . .. .. .. .. . . . . . . .. .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Under penalties of perjury,I declare 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 person responsible for filing the retum is based on all information of which preparer has
any knowledge. DATE
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN �I��f rr;
�LLi s�.r� , `Jt'� f -�
ADDRESS ��. �L� `�yf✓l�� �� 17070
l2H2 SHmh�i�'N�K' DATE
SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN
ADDRESS
i iiiiii iiiii iiiii i�i��ii��i�iiii�i�i�iiiii iiiii iiii iiii S,de z �
� 15056142�5
File Number
REV-1500 EX (FI) Page 3
Decedent's Complete Address:
DECEDENT'S NAME
('ia,r cr�r� 1���/,••��,•
_1���b�u� l3_�r,.,��� -----
STREET ADDRESS )ya E M�+k r, S�'
f�slZ �un�rn��'yien/ C-l�
—--------- ����„j� ��,1/� �A
— STATE Z�P
CITY {'A !'"16?a
New �"u,�,l.���i��h�.i.
Tax Payments and Credits: ��� �95 _ ��
1. Tax Due(Page 2,Line 19)
2, CreditslPayments
A.Prior Payments __-- —
B.Discount Total Credits(A+B) (2)
(See instructions.)
3. Interest �3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. �4�
Fill in oval on Page 2,Line 20 to request a refund.
�5� 29� •��
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.
LEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
P Yes
1. Did decedent make a transfer and: °
a. retain the use or income of the property transferrede�•'transferred or fts income .....................••••••••••••••.••••••� � �
b. retain the right to designate who shall use the prop y �
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 tleath on or after Jan. 1, 1995, the tax rate impfe? a survev n t pouse from taxeCand the statutory equ rement for ds closure of assets and
[72 P.S.§9116(a)(1.1)(ii)j.The statute does not exempt a trans 9
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 paren , an
adoptive parent or a step-parent 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,P Sce 9t116 a t(1a3)][A sbling9 s1define)d,
. The tax rate imposed on the net value of tras at least one�parent Sn ommon w th thesdelbeltlent he her bytblootl or adoption)
under Section 9102, as an intlivitlual who ha
REV-i5o8EX+(o8-iz) SCHEDULE E
� pennsylvania
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCETAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
FILE NUMBER:
ESTATE OF:
�-�„a�� ��.�y �3v�;���,yw
Inciude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclased on Schedule F• VALUE AT DATE
ITEM OF DEATH
DESCRIPTION
NUMBER
q y�9, co
1. r� f�� r u�,k C�c�J�i�q a��r.u„i"
TOTAL(Also enter on Line 5, Recapitulation) $ ��, �,99•ao
If more space is needed, use additional sheets of paper of the same size.
�E���'ll �X* `0�-�3, SCHEDULE H
� pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT FILE NUMBER
ESTATE OF
Decedent's debts must be reported on Schedule I.
ITEM AMOUNT
DESCRIPTION
NUMBER
A. FUNERAL EXPENSES:
1.
/[ p� ) +/ / [ �700 . c0
r"lifl't.Yl�f H��^ �LthGYa/ rttmC, f lde'rNA7CYi�
/
�'Yt:ra��in . 13ur�.�� G�ir . �%etS
g. ADMINISTRATIVE COSTS:
1, Personal Representative Commissions:
e�j�ra�i � �G1��r�ycr
Name(s)of Personal Representative(s)�
Street Address �2'�z Su m�''r✓�r w l"�"•
State 1�A ZIP T�7 d"10 —
City_.—��Cum�.G✓I�4h.:� — '�btl . ro
f ��t/ 7di�cl
Year(s)Commission Paid: _ »�"�r��T'�`°`� -�—
p • CA
2, Attorney Fees:
�f-s3 r--c-t�'
3. Family Exemption: (If decedent's address is not the same as claimanYs,attach explanation,)
Claimant__
Street Address______—_--- —
State ZIP— —
Clty--— ----
Relationship of Claimant to Decedent ---
f'�j�j. L p
4. Probate Fees:
�g . c o
5, Accountant Fees:
U . ot>
6, Tax Return Preparer Fees:
7.
TOTAL(Aiso enter on Line 9, Recapitulation) $ �0 3 y - � �
If more space is needed,use additional sheets of paper of the same size.
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I , �LAIR L. B�LLii`dG��, bt i�la�;ci��,�c�r i"cwri��hi� , `!ai-!� i::cai.!rltv ,
r'e��ns��l�iar:ia, dQclar� this io b:� cny l���t �ii l l und ri���r��;e �ny �li 115
previously made �y m�.
I .
I ciif�ct that a11 rny :juc,t c1pbl:a, -F�ir�c��-�a �r�d �,ur i,�l e;pE�ns�s�
anr� z.��E�nses af my l.��t illn��� at�ali be paid fr�m th� �s���t� o�f my
esiat� a� soon as p�a_»i.lale �t ter my CIE�'4.Eac15C�.
Ii .
I giv� ai-�d hAc�!�e�:th tr�F r-E�r�idu�� o�fi mv est�tc� or pvEry nati:re
an� wherever =si tu3t� urito my c1a+.�ghi;er' , i)�t�orah Fc�l. 1 in��pr .
iII .
�hou].d my sai.d d�uc-if�ter� a Deh�rah �c�IlinUer , predecease �-n� I
c�rve a57d h�qu�ath �:he �-E�SiduE of my e�t�t� untc� T�rry Lee My�rs, nnw
r�sidinr� ai 714 We�t F'Fiil�clel.phia �tr�et , Vot-i: , �'�ni7�ylv��nla.
3:V .
T aapai.nt my d�i.iqhter , Dehorah Bollincier , as my� Cxecutri;< ,
Should my aaid dauqt,i,Pr- r�r�.���ecea��e rne, ceas� or b�:. ur�atal� to ac�t as
my Executr�ix , T app�i.i��; I�er-ry L�_� (°l�;�r�, a.� F_;<ecut�r- .
1'J.
I �ir�ct ti��ar m�d F.;{ecu�ri;; nr E:�:ei��a�nr aha7. l root b� i-�quir-ad to
givc t�ar�ca tor the i��ai.{:h�tuJ per farrn�r�c:t o�r I�c�r c�� i-iis d:�cics in ar�y
jut-i�diction.
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f Tl'v' d¢d't rl • l7 f W t"i 3�:F��i�1 t";c3"�;l.t]-`_' �Z'i,i� CJ'V �;J(l.J ��_'`i'::'!' 1'_:Y'1'j Ci 1 t- t 1 O 11 1(Yl F]CJ�.�l� �
snc3ll t,e P�iid rrom n;�;• resici�_izrv esi.�t� a=, a u�r� � of th�e exp�ns�� c�f
the acl�r,inistrztian oT my e�?�at�=.
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fit�i i,JI���P.IE�SS WHC�1kOF , T h��ie herc:siito ���� rri�� t-��ar�c� ���i�-, _-�-,---_.____.__
��zY u f __L'��_.;_._____-_------, 1 Ga8.
� __.._..___._ _. � _ _'__ ____.____._-----
Ihe �rec�eding ii�strumpnty co;�sistiri� OT this and on� ( 1 > n�ther
typrJU�ritt�n page, c�ach idF�t�til=ied b�✓ the aignature af the Testate�r ,
v�aas c�n tflf' da�,� and dat� �;i�ere�f siqi�ed , Fuk�lis>>ed �nd declar�d by
CLAIR L. Bt7LLIt�JGER, the T�st��tor ther�in r�amed , as and 1'or �iis last
Will , in the pr�5ence ot us, �,iho a�E tii= r�quest , ir7 his presenc��
a�-id i n th� presen�_e o�F �ach other , h�ve �ubar_r ib�c:i our nan��s as
��ii tne�s�s het-eto .
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hlame__ \ _ -.�., -�----____'- ._ J�___:_.r��Gr��t'-�S_�______.____________�___'_----�--------1
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