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Home My WebLink About06-24-15 pennsylvania 1505614101 oernnrne 0FMVENM EX(03-14) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Bu PO BuBOX 280601 INHERITANCE TAX RETURN M =q Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � o � � � f A a:gT1g a7 Decedent's Last Name Suffix Decedent's First Name MI U,01ad 119 (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI i i iTn ® •■1111, 111111111E] THIS THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C=:) 1.Original Return p 2.Supplemental Return p 3. Remainder Return(date of death prior to 12-13-82) C=:) 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) C=:) 7. Decedent Died Testate p 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) C=:) 10. Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) O 13. Business Assets ® 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number � eNeL � o -1 � 3,f� a � AID: First Line of Address Ll r1 e, IZ J Second Line of Address c 1n n. O C_ 67 a City or Post Office State ZIP Code a0J I OL)-11y, I I I I I I 1 p / N t t� 311! p CD -. 7-- �3D _n •-rt Correspondent's email address: REGISTE12 bFNILLS US LY REGISTER OF WILLS USE ONLY ' �� CIS -T7 DATE FILED MMDDYYYY DATE FILED STAMP PLEASE USE ORIGINAL FORM ONLY Side 1 111111111111111111111111111[11�1lin 1gi111111111111111111 50 41 1505614101 1505614201 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. 101© � • 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. 1 *L-JLJ 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .... . .. 6. • 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Assets(total Lines 1 through 7).. ..... .... . .. .. ......... . .. . 8. 9. Funeral Expenses and Administrative Costs(Schedule H). . .. .. ..... .... . ... 9. 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1).. ... .. .... ... . 10. 11. Total Deductions(total Lines 9 and 10). .. ... .. .. .... . .... ... .. .... . .. .. 11.+ .� 12. Net Value of Estate(Line 8 minus Line 11) .. ... . . .... . .. .. ... ...... ..... 12. =_1101 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.' 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_ .� 16. 17. Amount of Line 14 taxable at sibling rate X.12 • 17. • 18. Amount of Line 14 taxable m at collateral rate X.15 • 18. I l 1, ` r t• 19. TAX DUE .. . . .. .. .. .. ... . ... . ... . . .. .. ..... .. .. ... .. .... . .. .. ... .. 19. 4 D• 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Under penalties of pedury,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. I AT RELF PE O RESPONSIBLE FO ILING RETU DATE s D o.�/ (�fn-I-�(s ADDRESS 15 Zoe"i ew 8e. PAYOU-) Q (ZO-Q-& SIGNATURE OF PREPARER OTHER THAN PERSON RESF90NSIBLE FOR FILING THE RETURN DATE ADDRESS Side 2 J 1 6 4 1505614201 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME L s SIRE A DRESS � I C STgTE ZIP !(J �t9 Tax Payments and Credits: .� 1. Tax Due(Page 2,Line 19) (1) 2. Credits/Payments A.Prior Payments B.Discount (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. 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 rNo•s�,, a. retain the use or income of the property transferred..............•........................................................................... ❑ ,lld. 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?...................................................................... ❑ 60 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ UL 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 60 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ 91 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)]. • 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 p2 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.