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Home My WebLink About04-02-15 J 1505610101 REV-1500 E"`0110' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY 280601 County Code Year File Number PO BOX 2 Bureau Individual.Taxes INHERITANCE TAX RETURN Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 01016 2 0 ] r10 111112 1 94 6 Decedent's Last Name Suffix Decedent's First Name MI N GY. E N . T R� I �1 -1 M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI NGUYENjjjjMAI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 5 8 6 5 8 3 0 7 7 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C:p 1.Original Return Q 2.Supplemental Return Q 3. Remainder Return(date of death prior to 12-13-82) Q 4.Limited Estate p 4a.Future Interest Compromise(date of Q 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 Q 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 Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number , 3 MAI 1 IT I NGUYEN71 78763 67�9 ; REqffEjPF WILLS-?ME 0 171 �3 (.f) .0 M .w First line of address N 70 " •7c b, 12141 ISI 1319TH I IST e nQ r1 Second line of address �O CO r=: rT ` City or Post Office State ZIP Code DATE F1 Y CAMP 1JI. ILILI I I I I I 1 1117011 Correspondent's 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 then the personal representative is based on all information of which prepares has any knowledge. SIGNATU OF PERSON RESPONSIBLE FOR FILING RETURN DATE / ADDR S / SIGNATURE R O R HAN E ENTATIVE D T -� i ADDRESS 2501 PAXTON ST. HARRISBURG, PA 17111 717-724_-0293 PLEASE USE ORIGINAL FORM ONLY ` Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ...................... ...................... 1 i ,y �I-_ •, -f, i i J . . ._� J 2. Stocks and Bonds(Schedule B) ............................ ........... 2. I, 3. Closely Heid Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. { J ��T�d_� ;� +J'i �L i 4. Mortgages and Notes Receivable Schedule D 1- - - 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5 J 1� _0I4! 7. JointInter�Vvo�s Transfers&Miscellaneous Non-Probate obate PropSeparate llei�g Requested ....... 6 � ��L3 1$ 6Y�,��7�2 rr•.�t��a J ' (Schedule G) O Separate Billing Requested.... .... 7. 8. Total Gross Assets(total Lines 1 through 7)......................... 0:01; Y1 P 5 L I 9. Funeral Expenses and Administrative Costs(Schedule H).... 9 4 5, 3 2 ,•Q I�011 _l �� - 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) .............. 10 �li `f k 5 !2 A 9 2 j #•0_0 !# 11, Total Deductions I total Lines 9 and 10 ...................... 4 6,010�J i i �0 !1 5 t 8 2 , �. 12. Net Value of Estate(Line 8 minus Line 11).............................. 12. 1{ .3 i2 7,-9 2; 6, 0 ho 13. Charitable an election t tax has of been Governmental Bequests/Sec 9113 made(Schedule J)rusts for which 13 14. Net Value Subject to Tax(Line 12 minus Line 13) ............. ........ ... 14.i,y ' i3 j'2 ,L7- 91 2 j 6OJ 0 I I TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers and Sec.9116 , = (a)(1.2)X.0-� -D,. 1 15 �! � f t' 0 !OFv 0 _ r3_� 2 7..';9 2 !6 0 '.01 -J �,� �� ,, 0 16. Amount of Line 14 taxable ) � '` at lineal rate X.0_ !'�_ �!f t. I_ Alt •,0 �OJ, 16 0 .� 0 17. Amount of Line 14 taxableat sibling rate X.12 k 0 �•0 '10 17. { � •0 0 0 18. Amount of Line 14 taxable at collateral rate X.15 OLL 18. 10 0 19. TAX DUE ........... .............................................. 19.�� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT t� Side 2 1505610105 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME TRI MINH NGUYEN STREET ADDRESS 24 S. 39TH ST. CITY � STATE ZIP CAMP HILL PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+8) (2) 0.00 3. Interest (3) 0.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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 29 a. retain the use or income of the property transferred;.......................................................................................... F]b. retain the right to designate who shall use the property transferred or its income;............................................ 11 29 c. retain a reversionary interest;or.......................................................................................................................... ❑ 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?.............................................................................................................. ❑ EX 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 nonprobate 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 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 72 P.S.§9116(1.2)[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+(11-08) enns lvania DE Y SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER TRI MINH NGUYEN 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 1' NONE TOTAL(Also enter on Line 1, Recapitulation.) $ If more space is needed,insert additional sheets of the same size. REV-1503 EX+(6-98) .. b SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER TRI MINH NGUYEN All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, NONE TOTAL(Also enter on line 2,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1507 EX+(1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER TRI MINH NGUYEN All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. NONE TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1508 EX a(157) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF TRI MINH NGUYEN FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE TOTAL(Also enter on line 5,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) RFV.ISM EX ab SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCETAX RETURN RESIDENT DECEDENT ESTATE OF TRI MINH NGUYEN FILE NUMBER If an asset was made joint within one year of the decedent's date of death,It must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A. MAI THI NGUYEN 24 S. 39TH ST., CAMP HILL , PA 1711 SPOUSE 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 identifying number.Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT dead for jointly-held real estate, VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 7/28/04 405 Orchard Lane, Mechanicsburg, PA 170515 $140,000.00 50% $70,000.00 2. A. 7/11/04 67 Kensington Dr., Camp Hill, PA 17011 $140,000.00 50% $70,000.00 3. A. 10/1/09 200 W. Green St., Shiremanstown, PA 17011 $160,000.00 50% $80,000.00 4. A. 6/24/01" 5 Rockaway Dr., Camp Hill, PA 17011 $140,000.00 50% $70,000.00 5. A. lmq 24 S. 39th St., Camp Hill, PA 17011 $120,000.00 50% $60,000.00 6. A. Members 1st FCU, Cqrtificate of Deposit $50,300.00 50% $25,150.00 7. A. Members 1st FCU, "a , G14l Account $ 5,153.00 50% $2,561.50 8. A. Centric Bank, Checking Account $16,921.00 50% $8,460.50 TOTAL(Also enter online 6,Recapitulation) $ 386,172.00 (If more space is needed,insert additional sheets of the same size) REV-1510 EX+(08-09) pennsylvania SCHEDULE G ® G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 THETRANSF:REE,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 R:AL ESTATE. VALUE OF ASSET INTEREST (IF APPacABLE) VALUE 1, NONE 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) Z pennsylvania . SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF TRI MINH NGUYEN FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. FUNERAL HOME EXPENSE $5,000.00 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: S. Accountant Fees: 6. Tax Return Preparer Fees: LUU LE DANG, P00235400 $325.00 7. TOTAL(Also enter on Line 9, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. 116-1512 EX+(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 NATIONAL MORTGAGE- $52,920.88 TOTAL(Also enter on Line 10,Recapitulation) 52,920.88 If more space is needed,Insert additional sheets of the same size. REV-1513 EX+(11-08) pennsylvania SCHEDULE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES . RESIDENT DECEDENT ESTATE OF FILE NUMBER TRI MINH NGUYEN 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 See,2116(a)(1.2).] 1. NONE 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 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN . 1 B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, $ If more space Is needed,insert additional sheets of the same size,