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HomeMy WebLinkAbout02-25-15 (2) 1505611101 REV-1500 Ex t02-11' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes DEPIRTIENTOfREVEIUE County Code Year File Number PO BOX 28o6o1 INHERITANCE TAX RETURN Harrisburg,PA 17128-0601 RESIDENT DECEDENT .1,6 d Q ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 06 1 b 2� 0 1 IO l °I l 9 59 Decedent's Last Name Suffix Decedent's First Name MI W At, �E K 1)U A rJ E, �-- (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI VJA I- � F, -9 CAR MEO L Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 16 2 5� a � 15- S REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 4ft 1.Original Return Q 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate Q 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) Q 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.) Q 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(Date of Death Q 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 o REGISTER OF WILLS USE r% r r`J f r7 First Line of Address ~ j Second Line of Address C.J I7. W City or Post Office State ZIP Code DATE FILED KF_C4 A C S 3 u 7'A I ? Q Correspondent's e-mail address: Olk QJ{� @ �IMa� t 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHE THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611101 1505611101 1505611201 REV-1500 EX Decedent's Social Security Number Decedent's Name: ' RECAPITULATION 1. Real Estate(Schedule A). .. .. .. . . .... ..... .. .. .... ....... . . .... ... . . . 1. 2. Stocks and Bonds(Schedule B) ... . .... .... .. .. .... . .. .. ... . . .. .. .... . 2. l b 3 • Q� 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. 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . .. .. .. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property �l (Schedule G) O Separate Billing Requested.. . . .. .. 7. 0 10 U v 8. Total Gross Assets(total Lines 1 through 7). . . .... .... . .... .... . . . . ..... 8. 3 3 d 7 9. Funeral Expenses and Administrative Costs(Schedule H).. . .. . . .. . . .. .. .... 9. ' l . V 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). .. ... . .. . .... . 10. 79 5 4 . t� E 11. Total Deductions(total Lines 9 and 10). . . . ... . ... ... . . ... . ... . . ... . ... . 11. 12. Net Value of Estate(Line 8 minus Line 11) .. .. . .. . ... . . ..•. . ... . . .. .. .. .. 12. i 01 . 0 13. Charitable 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. �' ?L, TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 l� D/ (a)(1.2)X.0& l [ 15. 16. Amount of Line 14 taxable at lineal rate X.0 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. f 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 15056.11201 J REV-1500 EX Page 3 File Number n r/ D t of Decedent's Complete Address: DECEDENT'S NAME UJalkfJ- 1 :D_uuyiet G STREET ADDRESS CITY % STATE ZIP L 3 17onr Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 2. CreditslPayments 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. 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 ............................................ El c. retain a reversionary interest .............................................................................................................................. El d d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 91 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? ........................................................................................................................ T9 ❑ 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)]. 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)]. • 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 172 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-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 ,. ISC O' + T mat-,^�f N-N-' g3 �5�t TOTAL(Also enter on line 2, Recapitulation) $ v!Z D (If more space is needed,insert additional sheets of the same size) REV-i5o8 EX+(ii-io) Pennsylvania SCHEDULE 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 v iJ 5v6tuL OLS6m�- b1-b,Oro TOTAL(Also enter on Line 5, Recapitulation) $ 50, If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+(oi-io) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE IJOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: W - ,� ua�i�- C-. o b 10 Z-1t,3 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. CQ�yl'INM Wat3� L� 4 S?pX)S e- B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT 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 ASSET INTEREST DECEDENT'S INTEREST 1. A. hj2D06 "D ' c,_� —�53L' 00OA5, OT, � -,0- 01 . 0111 b fe^ks �ui �� OLkLof� ltol-n 604 gol'" o°1 C l0 a3 ' :5001v ( 37 4 ,o ��°� 6) b�� I t5 lk•S• 60-Jln s -Blow-J<, �5� �0 5 ,�© 5� gn l o r� 1 �! lJI.,S� �g,�i,�s�nc�s v `fig,( SO�6 S�• � q@ � �, �qg� i�•s, �b��s TX1)j5 Ile 16b l� q3�-(Ob ba)o $ , C11 (k , ��, s� 1@ o � gl.?� Doig (k.5 � �°l�1 l �l•S� Scud s �o-n�s 1 � � � ' 1��, 1� ���6 1169 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 RESIDENT DECEDENT ESTATE OF oul VZA- C FILE NUMBER �O 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. VO� �� '�t t��ia� k��S `60.DD %--TICK r M q01 K #.q -t 79s 166-," Ab qo5:5t TOTAL(Also enter on Line 7, Recapitulation) $ 0-w '010 - 0 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 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 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: •,, �� i' ��. 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) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES DECEDENT, RESIDENT DECEDENT ESTATE OF FILE NUMBER 01^41 14 0 10 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 W61 I Mod &n 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: W 0�e�' L ao I q a 10 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. l.lc�� e,Vl L �Me.�lro��L PA' 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: r 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.