HomeMy WebLinkAbout03-23-15 (2) , � 1505611101
REV-1500 �`°�`° �
OFFlCIFL 115E ONLV
PA Department of Revenue �e��rybania �unty Coaa Vear Fle Numbe�
aureauorintliv;auatTaxes �� � � INHERITANCE TAX RETURN �.1 O � 4 � �
Poeoxzaoem RESIDENTDECEDENT 2 � � I
H b g PA � 8 6
ENTER DELEDENT INFORMATION BELOW
Soclal Secun�y Number Date o�Dea1h MM��YYYY �ate of BIrtM1 MA4D�YYYV
Suffix DacedenYs Flrs�Name MI
FF 2 � � e p�' �2 S �3 � 7"Ty 7
Q(Applicable) Enter Surviving Spouse's Iniormation Below
Spouse's Lasl Name Su(Gx Spouses Firsl Name MI
Spouses Social ser,uriry Numeer THIS RETURN MUST BE FIIE� IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� �. OrigioalReWm O 2.SupplementalReWm O 3' pnorto�12q3gp) �Dateo(�eaN
Q 4. LiITI�Bd ES18�2 '� 4B d¢ylll BIIEYP�e91 C0�pIOR115f(dd�B Of Q $. F2dBf81 ES�e�B Td%R¢W(�R¢O,II�IlBd
� fi. Decetlan�Died Tes'a�a O ]. Oecetlen�Meinteinetl a Living Trusl Q 8_Total Number of Safe Oeposlt Boxes
(A��acM1 Copy of Wul) (AtlacM1 CopY of Tmsl.J
O 9. Gtigfl�lon Prowetls Raceivetl O ��-Be�waeo 2 3�9� a�tl tDa��of Oea�M1 O ��� �qhach�Soheduly p�r Sec.9fl3(A)
COftRESPONDENT- THIS SECTION MUST BE COMPLETEO.ALL CORRESPONDENLE ANP CONFIOENTIAL TTX MFORMATION SHOIILO 6E�IRECTE�T0:
Name Daytime Telephone Number
ck2 �- 5 ICe � r� eR 7! 7 �3 `F•. 97,/, �
_–.
a[c��'r{acFwi��susEa.�C��,
� '�— -; 1
First line ofAtltlress �� � ' �
a
9 I t chzmb e2s STrZecT ' ,
SawndLineofAtltlress I � -
II
.OA?F Hi-e0 yS1- i
c�ry o�aos�oe���e sca�e na coae II_.. ._ ._ . — W -.., _
d� Ress I e2 P �F � � � r 3
c a a � iaa CKen✓� ev2.� $C � l}oL„ cGw� _
u�ee,penai���oi pe���y.i oeCe�e ina�i ne�e e.am��ee�ms�ewm.mu��m�q eccomperymq s=neames a�a ra�emen�s.ana m ene ees�or my k�owieaqe a�e oei�ar,
II I5�me,cortec�antl oomplele Declaretion of prepe�er o�M1ert�an 1�e personal rep�esenYaMe Is baseo on all Inlo�malion ot wM1icM1 preparar M1as eny knowledge_
SIGNAN F PERS N RESP NSIBL FOR FlLING RETUFN �A�
_�..,� � /��.�..�, � — o.3�a z�U/ �
nooaess 1
G//� C��' h.� �1C.t5 � �" /���eE: /2'� ✓ � / //�—_' __
SIGNATURE OF PREPARER OTHER THAN ftEPRESENTATIVE DATE
A�[JRE55
---- VLEASE USE ORIGINAL FORM ONLY
Side 1
J � l
L 1505611101 15056111�1 �
J
J 1505611201 .
aev-isoo ex
Decedenfs Social Security Number
oeceaenrsName'.,____ ___'__ �
RECAPITULATION
1. Real Eslale(SchetluleA). .. . .. . . . . . ... . .. . . .. . ... . .. . . . . ... . .. . . .. . . . 1. �
2. Srocks antl Bonds(Schedule B) ... . .. . . ... . . . . .. . ... . ... . . . . .. . . . . . . . . 2. � O 0 G, p O
3. Qosely Held Corporetioq Patlnership or Sole-Pmprietorship(Schetlule C) . . .. . 3. �
4. Motlgages and Notes Receivable(Schetlule 0) . .. . .. . . .. . .. . . .. . . . . . .. . . . 4. ,
5. Cash,Bank Deposits antl Mlscellaneous Personal PmpeNy(Sc�etlule E�. . . . . . . 5. I '� Q �. 1L s
!
6. Jointly Owned Propetly(ScheOule F) Ci Separa�e Billing Repuesletl .. . . . . . 6. �
]. IntervVivos Trans(ers 8 Miscellaneous Non-Probate Propetly
(Schedule G) O Separa[e Bllling Requestetl_ ._. . .. L ,
8. Total Gross Assets(lolal Lines 1 thmugh]) . .. . . .. . . 8. ?J 7 O �• aJ �
__- ___- ___. _._.
_______..__
._. __.._- __- _'_"_"____- _-_
9. Funeral Expenses antl Atlministra�ive Costs(Schedule H). . . . .. . .. . .. . .. . . . . g, � $ � U� � 5
10. Debts of Decetlen�, Mortgage Liabilities and Liens(Schetlule I�. . .. . .. . . . . . .. . 10. � y I , o p
11. Tolal Oetluctions(lotal Lines 9 antl 10)... . .. . . . . . .. . . . . . . . . ... . .. . .. . . . 11. � Q S I � G �
/
12 Ne[Value of Estate(Line e minus Line 11) .. . .. . . . . . .. . . .. . . . . . . . . .. . . . . 12 - 3-�3 y C � � y
13. Charitable antl Governmen�al BequesSBec 9113 Tmsls for which � �
an elec�ion lo tax has no�been made(Schetlule J� . . . . . . .. . . .. . . . . .. . . .. . . 13. ,
14. Ne[Value Subjec[to Tax(Line 12 minus Line 13) . . . . . .. . . .. . . . . . . . . .. . .. 14. p � B �'� �
TA%GALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES �
15. Amount ol Gne 14 taxable -
atlhe spousallaxra�E or
hansfers untler Sea 9116
(a)ft2)x o_ . 15.
16. Artrounl af Gne 14 taxable �
alllnealrale X.0_ _ � 16
1�. AmountotGnel4taxable
at sibling rale x .12 , ��
18_ Amoun�of Gne 141exeble
al collateral re�e X .15 , 18
19. TAX DUE . . . . . . . . .
. . . . . . . . . . .. . . . . . .. . . . . . . . . . . . 19. .
20. FILL M THE OVAL IF YOU ARE REpUESTING A REFOND OF AN OVERPAVMENT �
Side 2
L 1505611201 1505611201 J
File Numbe�
REV�15��EX Page 3
'DecedenYs Complete Address: �
�ECEDENPS NAME � ��
srReernooaEss �� q ��5� ,��� � � � �
��GC e.vti _� � V l ��_' - — —.
cirr� ._ _- __. .__ srnTE �J zia __
� n'l � l 0 2. l7 �_� �
i
Tax Payments and Credits:
i. rax o�a�Paee z,n�e is) (�l
2 Credi6lPayment5 Q
A.PnorPaymenis _. -
8.Oiscowt . - Total Credl�s(A�B) (2) _
3. Interest (3)
4. If Line 2 is greater(han Line 1 +Line 3,enter�he ditlerence. This is��e OVERPAYMENL (4)
Fill in oval on Page 7,Line YO to requesl a refund.
5. If�ne 1 �Line 3 is greater�han Line 2,en�er Ihe diRerence.This 16 the TAX�UE (5)
Make check payable to: REGISTER OF WILLS, AGENT.
� � PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl decedeni make a Iransfer and: Yes No
a. retain Ihe use or income of the properly transfened __.... .......... �--- ---- ❑ �
b- re�ein the right to designa�e who s�all use the pmpedy trensfer2d or its mcome -- ��� ❑� �
c. retainareversionaryinlerest ._...... .._._._ -���� ❑
tl. receive the pmmise for life of eilher paymenis benefits or care� -. ����
3. �id deceden�own ao in trust for"or ad decedenuransfer Droperty withm one year of dea�h ❑ �
Dec.12,1982,a
withoWreceivm ade uateconsideration?. _._..... _. _... - .
2 If death oaurteC a er
p yablrupoo-death benk account or securiry at�is or her deatM _.. ❑
ecedentoe�naryindrvitluelretirementaccoun� annuilyorothernonpmbatepmpertywhmh ❑ �
4 c�oolalns e bene�cie desgnalion� ......... _..-- --�-- ---' -"'
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 tlates of death on or aAer July 1, 1994,antl before Jan. 1. 1995,the�ax rate imposed on Ihe net value oi Iransfers ro or for the use ot�he surviving spouse
Is 3 percent�72 PS. §9116(a)(1.1)('i)I.
For dates of dealh on or after Jaa 1, 1995, the tax rate Imposed on the net value of iransfers to or for the use of�he surviving spouse is 0 percent
�l2 PS.§9116(a)(19)(li))-The steWte does wt exempt e Vansfer�o a survlving spouse irom lax,antl the staNtory�equirements{or tllsclosure ot assets antl
Flling a�ax retum ara sfill appllcable even I(Ihe surviving spouse Is Ihe onty bene(miary.
For dates oi tleath on or afler July 1,2000�.
. The tax rete Imposed on the net value o�transiers�mm e deceased chlld 21 years o(age or younger a�death lo or for Ihe use of a naWrel parent, an
adoptive paren�or a s�epparent of Ihe chiltl is 0 percent�72 P.S.§9116�a)�12)�.
. ThelaxratelmposedonihenetvalueofVansferstoorfortheuseofthedecedanl'sllneal6enefciaries1545pemen�,exceptasnoted'm(72P.5.§9116(a)(1)J.
. The tax ate Imposed on the net value o(transiers to or for the use of the decedenfs siblings Is 12 percan��72 P.S. §9116(a)(13)�.A sibling Is defined.
under Sec�ion 9102,as an individual who has at leasl one paren�in wmmon with the decedent,whe�her by blood or adop�ion.
0.EV:-502 E%- (O1-30;
��� 'i pennsylvania SCHEDULE A
°`°'"`"`"�o'°`"�`"�` REAL ESTATE
iv���v,oN�e,a*aerua�
acsmervr oeceornr
� FILE NUMBER:
ESTATE OF:
�_S 1-{ a �a -e �.1 � `I CJ `1 G (�
All real pm rty owned solely ar as a tenan[in mmmon must be reparteE a[fav market value. Fau ma�.ket value is Gefinetl as the pC[e at whlrn praperry
woultl be ex��anged Cete+een a w I ing Cuyer anC a wil�ing seller, neiNer being mmpel.eG m 9uV or sell,9o[h hawng ream�able knaweage of lne relevant facts-
Real pmperty that is joinHy-awn¢O with righ[ot survivarship mus[be EisdoseE an Schedule F.
Fttzrn a mpY o'r[he settlxmen[sFeet If'.�e pmoerty has been sold.
ITEM VF W E AT DATE
Include a mpy of tt�e tleetl shawing DececenPs in[erest If owned as tenan[im m�man. OF DFATH
NUMAE0. DESCRIPTION
1.
�'�
TOTAL (Also enter on Line 1, Recapitula[ion.) S
If more space Is neeGetl, use aGaifional sheets o!paper o!C�e same size.
REV-15W EX.�&B8�
� scNEou�E B
COMMONWEALTHOFPENNSYLVPNIA STOCK58BOND5
INHERITHNCE TR%FETUPN
FESI�ENTDECE�ENT
ESTATE OF FILE NUMBER
� a IN Gc� y
All pmperty lointly-ownetl witM1 right ai survivorship must be tlisclosed on ScheEule F.
REM VAW E AT DATE
NUMBER �ESCRIPTION OF DEATH
1
Y'1� �'t � ; �=.� . CO �Z � lo � �21 .J �C � °• c� t',
TOTAL(Also en�er on line 2, Recapitulation) $ a.GD� - ��
QI more epeca Is neatleQ insetl atldllionel sheets oi�ha seme slze)
���,�°°�"'0 �"� I SCNEDULE C
. � CLOSELY-HELD CORPORATION,
coMMon�wEn�rH oF PErvNsv�vnNin pARTNERSHIP OR
INHERITANCE TA%RETIIPN
aesioENroeceoeNr SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBEP
(3 e,�l"u 4 /+ �:_e d � /'-!oo Y 6�
Schetlu -1 C�2�1ncluding all supporting in�ormation)must be a�tecM1etl�or each closely-held corpara'ioNparinarahlp in�aras�of ihe decetlent o�M1erihan a
sola�propnatorship.See Insimcllons for iM1esupPohing intonnation m ba eubmNed for soieyropriebrsM1ips.
REM NUMBER VALUE AT�AiE
NUM6ER �ESCRIPTION OF DEATH
1.
I
�
TOTAL(Also en�er on line 3, Recapitulabon) $
(Ii more spece is needed,Insert adtli0onal sheets oi�he same size)
REV,���EX_`69Bj SCHEDULE C-7
�`� CLOSELY-HELD CORPORATE
COMMONWEALTH OF PENNSVLVANIP
���EA��^��E�^xRE��Rv STOCK INFORMATION REPORT
aEsioENr oECEOEr�r
ESTATE OF FILE NUMBER
�� oo y66
1. Name oi C ora . . _Stale on Incorporation
Adtlress . _ Date o�Incorpara�ion
City . _ _ �ate � Zip Code . Total Number of Shareholders
2 Federal Employer I.D. Number_ . . _ . eusiness Reporting Vear
3. Type of Business__ . . _ . . — _P�otlucVService
4� TYPE TOTA�NUMBEROF NUMBEROFSXARES VALUEOFTHE
STOCK yo�inglNorvVoting SHARESOUTSTAN�ING PARVALUE OWNEDBYTHEUECEOENT OEGEDENYSSTOCK
Cammon
$
Preferred §
Provitle all righLs antl restric�ions pretaining�o each class of stock.
S Was the tlecedent employetl by the Corporetion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �Ves ❑ No
If yes, Position_ . . Annual Salary S _Tme Demtetl ta Business
6. Was ihe Corporation indebted to ihe tlecetlent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �Ves ❑ No
If yes. provide amount of indebtedness S
Z Was there life insurance payable to ihe corporation upon the tleath of ihe tlecetlent? . . . . . 0 Ves ❑ No
If yes.Cash Surrentler Value$ _ . — Net pmceetls payable$
Owner of the pollcy
8. Ditl the decedent sell or transier an sbck in ihis company within one year prior to tleath or within iwo years
if�he tla�e ot tleath was prior to 1231-ffi?
❑Ves ❑ No If yes, ❑Transfer ❑ Sale Number oi Shares
Transferee or Pumhaser ._Considere�ion$ Date
Attach a separate sheet for adtlHionel iransiers antl/or sales-
9. Was ihere a wntten shareholtler's agreement in eHect at�he time of the decetlenfs death? _ . .❑Ves ❑ No
It yes,provide a copy ol�he aqreemen�.
10.Was tM1e tlecetlenfs srock soltl� ... . . . . .. ..... . . . . .. . . . . . ...... ❑Ves ❑ No
Ii yes,pmvide a mpy of the agreemen�ot sale,etc.
11. Was ihe coryoration dissolved or liquidatetl afler the decetlenYs death? .... ......... . . . ... ❑Yes ❑ No
If yes. provitle a breakdown ot distribu[ians received by the es�a�e,including dates and amount5 receiv¢tl.
12.Ditl IDe corporation �ave an imeres� in other carporations or pahnershlps? . . . . . . . . .. . ❑�es ❑ No
I!yes. repotl�he necessary informa[ion on a separe�e sheet including a Schetlule C4 or G2 for each in�erest.
• � • • • � �
A. �e�ailed calcula�ions used in Ihe valua�ion o(�he decetlenTs s�ock.
B. Comple�e copies of financial statemenis or Federal Corpora�e Income Tax reNms(Form 1120)br ihe year of tleath and 4 preceding years.
C. Ii the coryoration owned real estate,submit a list showing the complete address/es antl estimatetl fairmarkei value/s.If real estate appraisals have
been secureq anach copies.
D. List of principal stackholders a�the date oi death, number of shares held antl iheir relationship to the decedent.
E List of oificers,t�eir salaries, bonuses antl any other benefi�s receivetl fmm ihe corporetion.
F Statement ot tlividends paitl each yeac List ihose tleclaretl and unpaitl.
G. Any other information relating to�he valuatian af the decetlenfs srock.
(II more space is neadetl,insatl addilional sheets oi ihe aeme size)
i
pEV '��aEXY", ��, SCHEDULE E
�-� pennsylvania
ry� o p,,.E„,o,AE,EN�E CASH, BANK DEPOSITS & MISC.
iN„�u„w�e n=ae,�xv PERSONAL PROPERTY
eeso�r oEceoc+ar FILE NUMBER:
ESTATE OF: �/ � c/ �O c/6 �
�� Indu�pmceeds of li[igatlon and the date[he procee0s were receivetl by[he es[ate. /
All property join[ly owned with right of survivorship must be tlisclosetl on ScheEule F.
vnwe nr onre
ITEM DESCRIPTION OF DEATH
NUMBER
m�r ��.e�k, �� � ��.ti,.�:� i � �� � yS
TOTAL(Also enter on Line 5, Recapi[ulation) $
If more space Is nee0ed,use aGOitional sheets of paper of the same size.
REV-i5o9 EX+(olao)
� pennsylvania SCNEDULE F
� `°°"T"`"To""°`"°` 70INTLY-OWNED PROPERTV
�ti���,aN�E,a.a�-uaw
aesoerv�o�ccoerv*
FILE NUMBER:
ESTATE OF: _ / y ^� E��
� � ✓[a
If as became joinHy awneE within one year of the tlece0en['s date of dea[h, it musf be reportetl on 5[hetlule G.
SURVIVING]OMT TENANT(5) NAME(5) ADDRE55 RELATIONSHIP TO �KEDENT
A.
B. I I 1
U
C.
]OINTLY OWNED PROPERTY:
�enea onre DESCaIPTIOrv oF PRovEatt =m oF o4re aFceai��
RPt FO0.10IM YAUE IN0.UOENAMf04FlNTNCIAlINSfRUIIONPN�B�NKPCCOIIIENUM9E0.�fl9M1ONR �NiEOF�fFIH �ECEDPM1T'S MWEOi
NLMBER 1fNPM ]OINT IOENLIFYIN6NUMBE0..PIIACXDfE�FO0.i01MLYXfL�REPLfAiE. VBWEOfASSET I^lIFPEST �ECEOENTSIMEPE4
�. A.
TOTAL(Also en[er on Line 6, RecapitulationJ ¢
I!more spaw is neetled, use additional shee[s of paper oF the same size. .
pE�,s°sEx.`s-0°� gCNEDULE C-S
� PARTNERSHIP
`°""°"`"EA`�"�`PE��s�`vA��p W FORMATION REPORT
INHEPITANCE TAX RETURY
FESI�ENTOECE�ENt
FILE NUMBEH
ESTATE OF � y a���6 �
1� �����+� - � /
1. Name of Part ship_
Date Business Commencetl
Business Reporting Year_ _
Atltlress
S�ate Zip Code .
City
2 Federal Employer I.D.Number . —
3. Type of Business _ ProtlucVService _ _ - —
4. Decetlent was a ❑General ❑ Limited pannec If decetlent was a limited panner,pmvide initial investment$_ —
5. . . PE11C�M CAPffAl�llCCUiMt' . .
� �pAX7NEHNRME� . � OFIMCbNE� OFOWN�HSHW . .
A— .— — — — + I — — — . .—
I
B. . .— � . . — i — . —
C. . . . — — I . L. . — . — .
D. _I — — —
fi. Value of ihe decedenTs interest$ _ _ .
Z Was the Parinership indebted to ihe decetlent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Ves ❑ No
If yes,pmvitle amount of indebtetlness$_ . . —.
8. Was there life insurance payable ro the partnership upon ihe tleath of ihe tlecetlent? . .. . . O Ves ❑ No
Ii yes, Cash Surrender Value$ _ Net proceeds payable$ ._ .
Owner oi ihe PolicY. _ ._ — —. —. — — — . — .
9. Dltl lhe tlecetlent sell or Vansfer an interest in this parinership within one year prior to tleath or within two years ii the date of death was
prior to 1231-82?
❑Yes ❑ No Ii yes, ❑Transier ❑ Sale Percentage Vansferretl/soltl_ . _ —
Transferee or Pumhaser _
Consitleration$ . .Date _ _ —
Aflach a separete sheet tor adtlitional Vansfers antl/or sales.
10.Was there a written parinership agreement in etfecl at ihe time of the decetlenfs tleath? . . .. .. ��es ❑ No
If yes,provide a copy oi the agreemem.
11. Was the decedenYs paMership interes�soltl? . _ .. .. . . . .. _ . .. .. . . �Yas ❑ No
. . . .. .. .. . . . .. .. . .
Ii yes,provide a copy of lhe agreement of sale,etc.
12.Was the partnership dissolvetl or liquitlatetl atter the decedent's death? . .. . . . .. .. . . .. . . . . 0 Ves ❑ No
Ii yes,provide a breakdown of disfibutions received by the estate,inclutling dates antl amounts receivetl.
13.Was ihe tlecedent related to any of the partners? .. .. . . . .. .. . . . .. . . . .. . �Yes ❑ No
. . . .. .. . . . .. . .
If yes,explain_ _ . _ — — — � — — — �- — —
14. Ditl the parinership have an interest in other corporations or partnershipsY . . . . . . . .. ❑Ves ❑ No
If yes, report ihe necessary iniormation on a separate sheet, including a Schetlule C-1 or G2 for each in�eres�.
• � � • • � �
A. Detailed calculations used in the valuation oi the decedenYs paMership interest.
B. Complete copies of tinancial statements or Federal Partnership Income Tae retums(Fortn 1065)far the year of death antl 4 preceding years.
C. If Ihe parinership ownetl real estate,submit a list showing the complete atltlressles antl estimatetl fair mailcei value/s.If real estate appraisals have
been secured,atlach mpies.
�. Any other information relating to the valuation of ihe tlecetlent's partnership interes�.
ftCV-Ip0]E%+0-Wl
a� SCNEDULE D
�r � �
COMMONWEALTH OF PENNS�LVANIA
MORTGAGES & NOTES
E rp cE E AN I RECEIVABLE
FILE NUMBEH
s E oEc
ESTATE OF � .��� 6 O y 6�i
� All pmpe� r��j��ly-ownetl wi�h right o�surviwrsM1ip mus�be tlisclosetl on ScheCule F. VAWE AT�ATE
ITEM DESCRIPTION OF DEATH
NUMBEF
1 I "
�
TOTAL(Also enter on Ilne 4,RecapiWlafion) $
�I�mora spece is needad'�ruert etldl�ional sM1eek of Ne same size�
REV-151C E%+ (OB-09)
., � pennsyNania SCHEDULE G
��Pa�.MEN.oFAE�E�+�F INTER—VIVOS TRANSFERS AND
�NrEa„AvcErAxaE*�a�+ �I MISC. NON-PROBATE PROPERTY
FILE NUMeER
ESTATE OF n ,/
nJ a�v Y- /Y� "�-e .� / / `/ O b /� �
This Eole m�st be mmple[ed ana filed if the answe�to any of ques[ions 1[hrough 4 on page th�ee of the REV-1500 is yes.
DSCRIPTION OF PROPERTI' DATE OF DEATH °/o OF DECD'S EXCWSION TA%ABLE
ITEM mne--rrv<vsor.xaiva�ErxFlaFKar�oti�iFrc�K-mEv�o
NUMBER a.ecr'annve. a^acr�maroFrxe���enwaiesn*e. VAWEOFNSSET MTEREST �.i�r�voue�ei VALUE
1.
�
TOTAL(Also enter or. �'ne 7, Recapitulatlon) ;
If more space Is neeGeQ use atldi[ional sheets of paper of the same size.
0.EV-lill EX� p0�09;
� pennsylvania SCHEDULE H
� A.ME�roFAE�F�+�� FUNERAL EXPENSES AND
�NH�a�.AucE,AxaE,uan ADMINISTRATIVE COSTS .
a=smErvr oECEOErvr
ESTATE OF FILE NUMBER
2
� OO lo
Deceden['s debts must be reparted on ScheEule I.
NOME ER DESCRIVTION AMOUNT
A. FONERAL EXPENSES',
� muss��m� 1—uh eRak i� cm -e 7 g� � , 9 j
B. ADMINISTRATIVE COSTS:
1. Personal ReOresentative Commissions'.
Name(s)of Penonai kepresentatme�s� . ._ —. — —
StreetAGtlress _ .. —� -- — --
City � �__ _ ._ _ Sta[e ZID .. _ ._..
vear(s)Commission Paia: _ ._ . - — —� —
2. Attorney Fees:
3. Famiry Exemp[lon', Q(tleceGenPs aGGress is not Ne same as claimanPs,attach explanaUon.)
aaimant . _ -- --
StreetAGGress ._ . . .__ . -- �
Ciry _ __ _- — _ 5[ace_ __ ZIP ..
Relatianshl�ofClalmant[o Decedent _ __ —. �
4. Pmbate Fees', r � /jU
5. Aaoun[ant Fees:
6. Tax Return Preparer Fees'. � /� O C
N e�vs 9,�z2
,.
TOTAL(Also enter on Line 9, RecaDitulation) ; Yi l7 �j� . I I
If more space Is needed,use a4G'dfonal sheets of paper of Hte same size.
REV-1St2 EX+ p2-OB)
��� pennsylvania SCHEDULE I
„F,,,.„E„.��A��EN�.F DEBTS OF DECEDENT,
�n.�.ea�*F�.�e*+xaE-��a� MORTGAGE LIABILITIES & LIENS
aesmervroeceo xr
FILE NUMBER
ESTAT� � i / b'O -�—
Report rts i rreO by he detevE��iar[o dea[h that remained unpaid at the date ot Dea[h,incluGing unr mbursetl medical expenses.
VA.UE 4T CATE
ITEM DFSCRIPTION � OF DEATF _
NUN9F0.
1.
TOTAL(Also enter on Line 10, RecaDitulatlon) $
If more space�s neeGeQ inserc atltll6onal sheets of tne same size.
REV-1513 E%� (O1-IO) �
�� ' pennsylvania SCHEDULE ]
°"°a'"`"'o`"`°`""` gENEFICIARIES
INHEfUiPNCE TPX RRV4N
aesmervr oeceoervr FILE NUMBER:
ESTATE OF: _ / Ob/f6�
� � RENTIONSHIPTO DECEDENT NMOOF ESTATEARE
NUNBER AME AND ADDRE55 OF GERSONjS)RECEIVING PROPERTV Do Not List Tms[ee(s)
� TA%A9LE DISTRIBUTIO�A'S[Induae ou�t�g�htspo�sa�dist'Ihufore and transfers under
1. �
c-�Rti S KeP+�e�z F,� � ��
4�� cl., aw�6e,� s s7`
geessl� �� Pa i 7 �� 3
c R rv es7� ff l�e�°�'y e.Z � � I �� �
,a 3 3 �3��a 5 S �"
l-F= n-��sd �r,� �'e
�
EMEA�O�IAR AMOl1VT5 FOR DISTAI6UTIONS SHOWN ABOVE ON LMB 15 THROU6H 18 OF REV-150a NVER SHfET,FS APPROPRIATE.
11 90N-TA%A9LE DISTRIBUT;ONS
A- SPOUSAL�ISTdI8UT101V5 UNDER SELT.IOA 9ll3 FOR WMCH AN ELECTION TO TA%i5 NOT TAKEN�.
1.
B. CHNRITABLE AN�GOVERNMENTAL DISTRIBOTIONS'.
L
TOTAL OF PART II- EMER TOTAL NON-TAxABLE DISTRIBUTIONS ON LME 13 OF REVd500 COVER SNEEf. $
I(more space Is neeCed,use atldlnonal sheets af Oaper of the same slze.
RE`�,s,°Ex'�1�o31 � SCNEDULE K
LIFE ESTATE, ANNUITY
�oMMo�wEa�*��FPE��s���^��^ & TERMCERTAIN
INHERITANCE THX RETURN
aesioervi oeceoeNl Check Box 4 on REV4500 Cover Sheet
FILE NUMBEH
ESTAT�F � � N .
iL,P � �� DO ���O.E�
This schedul ' m b used for all single life,join�or successive life estate and term certain calculations. For tlates oi tleath prior to 5-1-89,
actuarial factors for single life calculations can be obtained trom ihe Depanmeni of Revenue, Specialty Tax Unit.
Actuarial factors can be fountl in IRS Publiwtion 145].Actuarial Values,Alpha Volume for dates ot tleath from 54-89 to 4-30-99,
and in Aleph Volume for dates of death imm 5-1-99 and IDereafter.
Indicate the rype of insirument which createtl ihe(uwre in�erest below and attach a copy�o the tax return.
❑ Will ❑ Intervivos Deetl of Trust ❑ Other
. .
DATE OF BINTH NEAPEST AGE AT TEPM OF YEANS
NAME(5)OF LIFE TENAM�S) OATE OF OEATH LIFE ESTATE IS PAVABLE
❑ Life or �Term oi Vears
❑ Life or �Term oi Years
❑ �ite or �Term of Vears
❑ Life or 0 Term of Vears
❑ Life or O Term oi Vears
1. Value of fund iwm which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2. ACWarial factor per appropriate table . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . .
Interes�table rate-0 3 V2 e ❑ 8% ❑ 10% ❑ Veriabla Rale —.o
3. Value of life estate(Line 1 multiplied by Line 2) . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
�
OATEOF6111TN NERPESTRGEAT TEPMOFYEAPS
NAME�S)OF LIFE pNNURANT�S) OATE OF OEATN ANNUIiV IS PAVABLE
❑ Life or O Term ofVears
❑ Life ar O Term oi Vears
❑ Life or 0 Term of Years
❑ Life or 0 Term of Vears
1. Value of�untl�mm which annuity is payable . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ .
2 Check appropriate block below antl enter correspontling (number) . . . . . . . . . . . . . . . . . . . . . . . . . .
FrequenCy of payou�-0 Weekly(52) ❑ gi-weekly(26) ❑ Monthly (12)
❑ Quartedy(4) ❑ Semi-ennuelly(2) ❑ Annually(1J ❑ Olhe�( )
3. Amount of OaYout Per periotl . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual paymen�, Line 2 mWtiplietl by Line 3 . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . —
5. Annuiry Factor(see insimetlons)
Interest table ra�e-0 31/2% ❑6% ❑ 10% ❑ Veriable Rate_ -�
6. Adlus�ment Factor(see insimctions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . .
Z Value of annuity- Ii using 3 V2%. 6%, 10%, or If variabla rate antl periotl
payout is at entl of period,calculatian is'. Line G x Line 5 n Line 6 . _ . . . . . . . . . . . . . . . . . . . . . . .$ .
If using variable rate antl periotl payoutis al Deginning of periotl,calculation is:
(Line 0 x Line 5 x Line fi)i Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ _
NOTE'The values of ihe funtls which create�he above future interests must be reported as parl of ihe estate assets on Schedules A lhmugh
6 of Ihis tax retum.The resulting life or annuiry interest(s) shoultl be reponed at�he appropriate tax rate on Lines 13 antl 15 through 18.
(II more space is neetla4 lnserl addi�ionel sM1eets oi IM1e same slze)
eEv-iean ex+ (oi-io7
� INHERITANCETAX
��r�`�: pennsylvama SCHEDULE L
�rvnenrrneceT�ae*uaN REMAINDER PREPAYMENT
aesroe�+roeceoeNr pR INVASION OF TRUST CORPUS
I. ESTATE OF
FILE NUMBER
�3 e.,�n�e. — � I iyoo�/6� —
7his sc dule is appropriate onty for estates of Aecedents dying on or before Dec. 12, 1982.
This schedule is to be used for all remainder reNms wM1en an election to prepay has been filed under the provisions of
Section 714 of the Inheritance and Estate 7ax Act of 1961 or ro report the invasion of trust mrpus (principal).
II, REMAINDER PREPAYMENT:
A. Election to Prepay Filed with the Register of Wills on - (Date)
B. Name(s) af Life Tenant(s) Date of Birth Age on Date Term of Years Inmme
or Annuitant(s) of Election ar Annuity is Payable
C. Assets: Complete Schedule L-1
1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . .$ __ —. I
2. Stocks an0 eonds . . . . . . . . . . . . . . . . . . . . . .$ � �
3. Closely Held Stock/Partnership . . . . . . . . . . . . .$ _ __
4. Mortga9es and Notes . . . . . . . . . . . . . . . . . . . .$ __ .
5. Cash/Misc Personal Property . . . . . . . . . . . . . .$ __ . - ..
6. To[al from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ _ .
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . .$ _ _
2. Unpaid eequestr . . . . . . . . . . . . . . . . . . . . . . .$ _ —
3. Value of Non Indudable Assets . . . . . . . . . . . . .$ _ __
4. Total from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ — --
E Total Value of Trus[Assets (Line C-6 miws Line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . .$ __.
E RemainderFaztor " " " " ' " " " ' � -
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G. Taxahle Remainder Value (Multiply Line E by Line F) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . _
(Also enter on Line 7, Recapi[ula[ion)
III. INVASION OF CORPUS:
A. Invasion of Corpus ..
(Month, Day, Year)
B. Name(s) of Life Tenant(s) Da[e of Birth A9e on Date Term of Years Inmme
or Annui[ant(s) Corpus or Annuity Is Payable
Consumed
C. CorpusConsumed � � � " " " " " " " " " '$ — �
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. RemainderFactor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —
E. Taxable Value of Corpus Consumed (MWtiply Line C by Line D) . . . . . . . . . . . . . . . . . . . .$ _ . .
(Also en[er on Line 7, Recapitulation)
dEV-t6ns Ex+ (ll-09)
INHERITANCE TAX
i� pennsylvania SCHEDULE L-1
Ca7
�rvNca:rnncevaReruvu REMAINDER PREPAVMENT ELECTION
e�soevr oeceoervr -ASSETS-
I. ESTATE OF FILE NUMBER
� � � - � OD f�lo
II.�I�NO.' DESCRIPTION VALUE
A. Real Estzte (Please descrlbe.)
� n� \�
\
Total Value of keal Estate $
(Indude on Section II, Ltne G1 an SchedWe L)
� B. Stocks znd Bontls (Please list.)
Total Value of Stocks an0 Bonds 5
(IncluLe on Section ][, Line G2 an Schedule L)
i G Cloiely Held S[ock/Partnershlp - Please Ilst (At[ach Schedule C4 antl/or G2.)
I
r TO[dl Valu2 of CI05¢ly Held�Pdf[nership 5
' (Indude on Sectian lI, Gne C-3 on Schedule L)
D, MoGgages and Notes (Please IrsL)
Total Value of Mort a es and Notes $
I 9 9
��. (Include on Section II, Line C-4 on Schedule Lj
'�. E. Wsh and M�uceilaneous Personal Property (Please lisc)
I� II Totel Valua of Cash/M3cellaneous Personal Property 5
Qndude on Se:tion II Line GS on ScheOule L.)
III. �I TOTAL (Also enter on Sec[ion II, Line C-6 on Schedule L,) � S
If more Space IS needed, attaCh adORional 5heet5 Of paper of Ine Same 51ze.
ae:iaeae =_x+ U i-o9)
INHERITANCETAX
�jii� pennsylvania SCHEDULE L-2
L,�? a,n x.o� aE�E��,
mneF-anceraxaErdarv REMAINDER PREPAYMENT ELECTION
eesmevr ov�eoerv- -CREDITS-
I. ESTATE OF FILE NUMBER
� �� / YOD�/G�
II. ITEM NO. DESCRIPTION AMOUNT
A. Unpaid Lia6llltles Claimetl agains[Orlginal Estate antl Payable from Assets
ReDorted on Schedule L-1 (please list)
7otal Unpaid Liabilities $
(indude on Section I[, Line D-1 on Schedule L)
B. Unpaid Bequests Paya6le from Assets Reported on Schedule L4 (please list)
Total Unpaid Bequests $
(indude an Sec[ion II, Line D-2 on Schedule L)
C Value of Assetr Reported on Schedule L4 (other than unpaid beque5[s listed
under"e" above) that are Not Induded for Tax Purposes or tha[ Do Not Porm
a Part of[he Trust.
Calculation as fallows:
Total Non lndudable Assets 4
(indude on Sec[ian II, Line D-3 on Schedule L)
III, TOTAL (Also enter on Sectian II, Line D-4 on Schedule L) $
If more s0ace is needed, attach additional sheets of paper af the same size.
�i . iH:F.. i:,_.m �
�, SCHEDULE M
. � pef1f15Y�Vall18 FUTURE INTEREST COMPROMISE
� o a�M .��Fa
��"FA�T""�`T°'A'�'� ([heck 8ox qa on REV-1500)
aes�oemr oFCFOFnT
ESTATE OF FIIE NUMBER
� �� � / � �6 `/� F
This sch ule i pP�opriate anly for esta[es ot tleceden[s who died aker�ec 12, 1982.
-his schedule is ro be used Por all fuvre In[eres[s where [he rate of Lax[hat will be appliable w�en the�uNre mreres[ves.s in
possession antl enjoymentcannat be establishec with �ertainty.
Indiate Oebw the type of instrumen[tha[created [he fumre mteres[and atta�h a copy tc Che[ax retum.
❑ Will ❑ 7rust ❑ Other
I. Beneficiaries AGE TO
NAME OF BENEFIQARY RELATIONSHIP �ATE OF BIRTH NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decetlents who died on or after]uly 1, 1994, if a survrving spouse exer�seo or inrends ro exercise a ngh[of witharawal wi[hin
nine months of the decedenPs tleath, checx che appropnate boz below anc a[[ach a mpy o°the documen:in which the surviving spouse
eaercises such wi[hdra�val �ight.
❑ Unlimited right of withdrawal ❑ Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amountoffuture m[erest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
L Value of Line 1 cxempt from tax as amount passing m charities, e:c.
(Nlso indutle as part of ro[al shown on Line 13 of REV-1500.) . . . . - . . . 5
3. Value of Line 1 oassing [o spouse at appropnate Gx �aCe
Check onc. ❑ 6%a, ❑ 3%. ❑ 0`� . . _ . . . . . . . . . . 5
Also indude as part of[o:al shown on Llne 15 of REV-1500.)
4. Value of Line 1 :axable at lineal rate
Che�k onc. ❑ 6°ro, ❑ 4.5°% . . . . . . . . . . . . . . . . . . . . . . . . 5
(Also mdudc as part of to[al shown on Llne 16 of REV-1500.)
5. Value oF Line 1 [aKable at sibling ra[e(12°%)
(Also indude as part of roal shown on Line 17 of REV-1500.J _ . . . . . . . 5
fi. Value of Line 1[aKable at mllateal ra:e(15°b)
(Also intludc as part of rozl shown on Cme 18 of REV-1500.J . . . . . . - . 5
7. Total value of Future interest (sum of Lines 2 thm 6 mus[equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . 5
If more space Is neetletl, use atld�tional sM1ee[s of paper of[he same size.
FEY-1669 EX�(08�09�
r pennsylvama SCHEDULE O
oEoaa�ME..o, w��E��E
�rvHEFRnrvCETA�SHENwa ELEQIONUNDEHSECmf13(p)
AesIDENi oe[EDErvi (SPOUSAL DISTNIBUTIONS)
ESTATE OF FILE NUMBER
ooY6
�o not comp this schetlule unless the es[ate is making the election to tax assets under Section 2113(A) of the InheriWnce anE
Esta[e Tax Ac[.
If[he eleccion ro more than one[mst or similar arrangemenq a se0aate form mus[be Flled Por eachusts(marital,resiCual A, B,by-Oass, UnifeO Creeiq etc.).
Thls elec[ion applles to[he - —
If a[mst or similar arrangemenl meets[he requiremen[s of Sec[ion 2113(A)antl'.
a.The tmst o�similar arran9ement is listed on ScheGule 0 an0
b.The value of Ne tmst or similar artangement is entered in whole or in part as an asse[on Schedule Q Nen the transfemr's personal represen[a-
tive may specifically Iden6fy[he hust(all or a fiaQlonal portlon or percentage)to be Includetl In Me elec0on[o have such hust or smllar proper-
ry treateG as a taxable trarefer ln Ihis esta[e. If less than the entlre value of Me tms[ar slmllar Droperty is Inclutle0 as a taxable transfer on
Schedu!e 0,Ihe personal representative shall be mnsidered ro have made the elec[ion only as ro a fraction of the tmst or similar arrangemen[.
The numeramr of Mis fractian is equal to Ne amount af Ihe hus[or similar arrangement intluded as a taxable asset on Schedule 0,The denomi-
na[or is equal to Ihe total value o!Me tmst or similar arrangemen[.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the
decedent's surviving spouse under a Section 2113(A) trust or similar arrangemenL _
— oescnpno� vai�e
Part A Total S
PART B: Enter the tlescription and value of all interests induded in Part A for which the Section 2113(A) election to tax is
being made.
Desctiv��on Value
Part B To[al $
If more space is neeEeO,use a0di[ianal sheets of paper of Me same size.