HomeMy WebLinkAbout04-23-15 pennsytvania 1505614105
"�'O@APMFNf OFR.E E EX(03-14)(FI)
REV-OFi�OO OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN �� I ` p
Harrisburg,PA 17128-0601 RESIDENT DECEDENT t `(�j�
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
?! 3 0. &VI
Decedent's Last Name Suffix Decedent's First Name MI
L"I
(If Appli able)Enter Surviving Sp se's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
-
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1.Original Return O 2.Supplemental Return p 3. Remainder Return(date of death
prior to 12-13-82)..
O 4.Agriculture Exemption(date of O 5.Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
i 7.Decedent Died Testate O 8.Decedent Maintained a Living Trust 9.Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
O 10.Litigation Proceeds Received O 11.Non-Probate Transferee Return O 12. Deferral/Election of Spousal Trusts
(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 TO:
NameDaytime Telephone Number
----------------- - - ------ - -------- ----------------------------------- ---- ---- --- -
'11'7 - ���-7��s
First Line of Address
Second Line of Address
City or Post Office State ZIP Code
Lorre pondent's email address: T�Q/Y►'1 S� �n \/'-e_t) 7 d Y)
REGISTER OF%1kL SE ONLY^� C)
REGISTER OF WILLS USE ONLY (r� n
DATE.FILED MMDDYYYY - „ (-'- IV '
• 4
DATE FILED STAMP ►—►
ry r
t �j o
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505614105 1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name:
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1.
2. Stocks and Bonds(Schedule B) ....................................... 2. gam)
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. -�---111---
4. Mortgages and Notes Receivable(Schedule D)........................... 4. t
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5.
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. D sq
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property If
(Schedule G) O Separate Billing Requested........ 7. y, 2
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 5 lc> 7
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9.
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 1 n U A
11. Total Deductions(total Lines 9 and 10)................................. 11.
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. Q
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which �U
an election to tax has not been made(Schedule J) ........................ 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14.
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 °S J 11 S J�1 16, 3Li
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
19. TAX DUE .......................................................... 19. �' 1 ✓ 1 h
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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 return is based on all information of which preparer has
any knowledge.
SIGNTC�OF PE SO RESPONSIB E OR FILING RETURN DTE
`n4-la - (S
Ari� S� AA\e y\ 1'1 oSS
SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBEE-ffOl FILING THE RETURN DATE
ADDRESS
Side 2
1505614205 1505614205 J
REV-1500 EX (FI) Page; File Number 11
Decedent's Complete Address: C� I'
DECEDENT'S�NA,ME ^^ /
VV C�Y
i 1 Jr s
ST EET ADDRESS
off-
CITY ( �K); STATE V17 ZIP C�7
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1)
2. Credits/Payments 0o T
A.Prior Payments Cosa
B.Discount , J j
(See instructions.) 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. :Amo ,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..........................................................................................K ❑
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?...................................................................... ❑ 7K
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 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 step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
1 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(a)(1)].
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,(8-1z) '
ffpennsytvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF � FILE NUMBER
a n C��Y� '3 - l �j
All property jointly owned ith right of survivors .must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
I l
I
I
i
TOTAL(Also enter on Line 2, Recapitulation) $ p� 7,D9
If more space is needed,insert additional sheets of the same size
REV-15o8 EX+(08-12)
[ J pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: A FILE NUMBER:
, s 3 0n
Include the pr ceeds of litigation and th to the proceeds were received by the estate.
All property jointly owned with right of lsdrvivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
9 S-
4&C
s
C�CX X t
. _ k�r�j-�,v� 5�-�°_r-�-oil'►-�- (�n;�r �
�- a0}�
;.� Cpm M: �J- •Q }�, . - PDQ� x.� e a�'�.L9�a3 3 . _ _ .
�•
X1.1 �b1'� Svc . off_ .oa=
t
ta .1_ L.c- '► 1 �_ Ovid- _ LIQ a.g_-a
l� J t�r_a 2_�. ►:�s,. ��.,��-1_02 -t�l C.o b U.►-
, �� d
!'Act r7.,. 73!
t _ -
TOTAL(Also enter on Line 5, Recapitulation) $
If more space is needed,use additional sheets of paper of the same size..
REV-15og EX+(oi-io)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
If an asset became jointly o ed within one year of decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
i
C. - -
JOINTLY OWNED PROPERTY:
LEITER 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.
?io� IT nCa , r,
. � ►__ �A-►. - ��I a �.���/�� �� y .sod, Via,a42 yq
SDI, j31 ass, bS
I
F I
7
TOTAL(Also enter on Line 6, Recapitulation) $ l 1:1 14 '_
If more space is needed,use additional sheets of paper of the same size.
REV-1510 E,X+(02-15�)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
in 1 ��rA15S
This schedule must becompl ted and filed if the answer any of questions 1 through 4 on page three of the REV-1500 is yes.
!
ITEM DESCRIPTION OF PROPERTY. DATE OF DEATH %OF DECO'S EXCLUSION TAXABLE
INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE VALUE
1----� - 33,Sas a3
d OS 3
__.__---- — — -- — — — ------------------------------ , --------------
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• -----------•---- - --- ,- ------- _ �..�.„ - --------------------------
------
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1 F
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TOTAL(Also enter on Line 7, Recapitulation) $ ';33as�a3i!
If more space is needed,use additional sheets of paper of the same size.
REV-1511 ER+(08-131
iffpennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
EST)TE OF FILE NUMBER
a �
) s c l l
Decedent's deb must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
3= �-u n b,"nlfn" l - ba
_--�-�---- _ �a a
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: �_ r
Name(s)of Personal Representative(s)`
Street Address�Q3 i
city ���+1���{{{ 00 State ZIP
Year(sCo mission Paid: ( /J
Z. 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: l�V Y'\-)S —l A�J—
5. Accountant Fees: I
6. Tax Return Preparer Fees: C"'
7. til—
V-e-Al
�i _�J vnlb ._�►���bJ�-r-�---�"�v•?.,r;�i S t.ne�.� __ �s",c7�
�o S P-1 P- -e PSP 6a s- s Ls� A-%<,"
° ► (I 3 �l01, se @ �-, Q Sa ' l,O,.c150 , 7.5
TOTAL(Also enter on Line 9, Recapitulation) $
If more space is needed,use additional sheets of paper of the same size.
��' �^�- ,� �-���.;���.. .b�1�.�..� S vim',--�c..�.. �� � 5
REV-1512 EX+(12-12)•
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
EST TE OF FILE NUMBER
�
Report debts incurred by the jecedent prior to death dat remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
_q-13 + -3-i� oo.�
�5�e-c-)—J_
Sr- 13 —tall Li)
La
\jo,-T-N Z'D 0
10 v L
I
P/vc- �- - CGS-ed - C6--raL Gln loci , `1 to
54 -�
'Pe. C� v "-r�t
I 4-w �,sa
TOTAL(Also enter on Line 10, Recapitulation) $ I o
If more space is needed,insert additional sheets of the same size,
REV-1513 Ek+t01-107
pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE
_ .INHERITANCE TAX RETURN BENEFICIARIES .
RESIDENT DECEDENT
ESTATE OF', , J FILE NUMBER:
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS PERSON(S)RECEIVING 6PERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1,2).]
- - - '"1.
am
......
"-1" -J
,
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1
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--- _ _ - ��. ----•-•---•--------•- -
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------------
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:
�
-_-_.....-- —....------•------------••---•--•--------------------••------- •--- ---
-'
-,-^�c^��:».--.•--W-�-cati:�_-..w,,._z+�-�. �_—�-a;._..�."r.. `-mac—.�_r.=_,..—'�r�-�-�"�-__..�---_....
--------------
5 -
I � i
----�
—-----------------------------------------------•----------------.--- —.... -------..............................
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'
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1 -----------••---------------------__.......... - •--------..........------- .. -------- --- _ - -
•
1.______.__-.___"...:..................... "___"___---"-___. .__._..___.__--__-".-_-.""----
_ I
_----------------
----------
___---------------------------------
_T--.�--------------
I I
1
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.
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