HomeMy WebLinkAbout07-23-15 (2) oennsy�vania 1505614101
J ��..w.umaaar: �(m.�al
REV-1500 OFFICIAL IISE ONLY
Bureau of InOivitlual Taxes Counry Cotle Vear File Number C
vo eox zaaeoi INHERITANCE TAl( RETURN /� I I S � 2�0 g
Harrsburg PA v128-o601 RESIDENT DECEDENT �/
ENTER�ECEDENT INFORMATION BELOW
Social Security Number �a�e of�ea�h MMDDYVYV Date of 81r1h MMO�V1'1'V
o �3ja� i3 / l l `� lq3�f
�ecetlenPs Lasl Name SuRx Oec tlenl's Firs�Name MI
j-� �� -� �;n,�a � j��crr� fl
(If Applicable)Enter Surviving Spouse's Information Below
S�pous1e's Last Name SURix �Snpause s Flrst Name MI
.��1. �( ��"�fj'��.� . lT�� I �./��'v �
THIS RETURN MUST BE FILED IN DUPLICATE H THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Onginal ReWm O �� Supplemental ReWrn p 3. Remain0er ReWm(tlate of death
prior la 1213-ffi)
p 4.AgriculWre Exemption(dale of p 5.FuWre Interest Compmmise(tlale o( p fi. Fetleral Estale Tax Remm Requiretl
tleath on or after I-1-2012) deatM1 afier 1Z12-B2)
p ]. �ecetlen[Dietl Testate O 8.Decedent Maintained a Llving Tmst � 9. Total Number of Sale�eposit Bozes
(Atlachcopyofwill.) (Attac�copyof�mst)
p 10. Liliga�ion Pmceetls Received O 11.Non-Probate Transferee ReWm O 12. OeferzaVEledion of Spousal Tmsfs
(Sahetlule F and G Assets Only)
O 13. Business Assels � 10.Spouse is Sole Benefciary
(Nolrustlnvolved)
GORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESFONOENCE ANO CONFIDENTIAL TA%INFORMATION SHOULU BE OIRECTEO T0:
Name Daylime Telephone Number
�Ql�}{�� �a��� n �-1 � � l� � ��7
FrstGneolAtldr s
��D� ��ct�'i�n�
Secontl Line of Atldress
�C(ty or Pos��ce/ /' S�te ZnIP Cotle �I
�/�� '. � "`�� . � / � � " ��✓ . . .
Correspondent's email atldress:
REGISTEk OF WILLS USE ONLY
REOISTER OF W ILL3 O6E ONLY
. � DiITE FILED MMDDYYYY �
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VLEASE USE ORIGINAL FORM ONLY� �� ' -': n
Side 1 -� -, W � m
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J 1505614201
RE�-,50�EX
DecedenPs Social Secu�rit�
REGAPITULATION
1. RealEsla�e(SchetivleA). . _ . _ .... ....... .. . . . . .. . _. . 1 ����� vy
f �J��,
2 S�ocks antl Bonds(Schetlule B) . . . ... ... .. . .. . . . . .. . .. . .. . 2
j � � �4 �
3. Closely Heltl Corpora�ion, Partnership or Sole-0roprietorship(Schetlule C) . .. 3 i,
xr, =
4. Mortgages antl No[es Receivable(Schetlule�) .. . .. . . . . . . . .. . .. 4 ,i,
�
' : . C �.r XY4
5. Cash, Bank Deposits and Miscellaneous Personal Pmperty(Schedule E . .. . . 5 �
� � ��. �B� �S,
�-/��
8- Joln�ly Ownetl Pmperty(Schedule F) O Seperete Bllling ReQues[ed ____ 6 ` V /
1. In�er-Vivos Transfers 8 Miscellaneous Non-Pmba[e Propetly ��"�fx��
(Schetlule G) O Separa�e Billing Requestetl . ... . ] �(.f
e . s:t —/u� • • � .4
8. Total Gross Assets(to�al Lines 1 throogh ]) . .. . .. . . . . . . .. . .. . .. . .. . 8 D,� `(/' � ���
9. PoneralExOensesandAdministrativeCosS(SchetluleH)..� .. . .. . . . .. . 9 � �/�`�O�
� . �F "^5,.,.,_...�.�:
10. Oebis of Decedent Mortgage Lia�ili[ies and L ens(Schedule I) . . . . . .. 10 d .� J��/
.. . . . J �w�P,',WP�';
11. Total Detluctions(total�ines 9 and 10). . . . . .. . . . . . .. 11 /
/} x
�h/ �'�{✓Nf re /r�� wi
12. NetValueofESTate(LineBminusLinell� . _____ .. . . . . .. 12 iJ�[/�� �;jy��
✓ " . . ,4F �
13. Chari�able an0 Governmen�al BequestslSec.9113 Tms�s for which � ' _
an elec[ion to tax has no[been made(Schetlule J) . .. . . . . .. . . 13 � �
14. Net Value Sub�etl lo Taz(Llne 12 minus Line 13) . . _ . _ . . 14 ���'�y`��
TAX CALGUL4TION�SEE INSTRUCTIONS FOR APPLICABIE RATES
15. Amounl of Line 14�axable
at ihe spousal tax ra�e,or
Irensfersund�Sec.9116 ���/ �D+ y�y.�
�ax, z�x a 7 �� ,s �
18. Amount of Line 16 taxable �� ����q " '�
atlinealrate X.0_ . � i6 � � �
1]. Amoun�of Line 14 taxable � . . .��
at sibling rale X.12 ' � � � � . . ��. �
�
18. Amoun�of Line 141axable ��� � � � � �'
at rqllateral rate X .15 . • �� 18 � � ,r'y .r�
19. TAXDUE . . .. . . .. . . . . . . . .. . . . .. . . .. . .. . . 19 . . . �� VV
20. FILL IN THE OVAL IF YOII ARE REqUESTING A REFUNO OF AN OVERPAYMENT p
Untle�penaWes of perlury,I detlare I M1ave examinetl Ihis reNm,Inclutling acrnmpanying scM1edules and slalemenLs.antl lo iM1e Casl of my knowlBtlge antl balle(
i�is�me, mrtect and mmplete. �eclara�ion of preparer ol�er�M1an I�e person responsible br filing�be raW m Is Dasetl on all information ol wM1icM1 preparer M1as
any knowletlge.
SIGN'.Tl1R�R3QN RE SIBLE PoR FlLING RETORN
/ onr� /
L � G�c, r�I'1'v`— ,, ' ,,\ /p ,, ��j �l /°� /�
nooaEss/ ' al //�� �iV U li L�l!'� l Q [�
S EPA ER OTHER TH ERSON SPONSIBLE FOR Fl N THE RET R , ` ' DATE
1 �J �Q.�.
H4�RE55 „„ I/� � ' O 1 �
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iiiiiiiiiiiiiiiiiiiiiuuiiiiiiiiii�i��iiiiiiiiiiiiiiiiii S�dez
L 1505614 1505614201 J
REV-150�EX Gage 3 Flle Number
DecedenYs Complete Address:
oECEOENrs Nnrn (�� f`7. �l�'���Y1c11'7 � c�
sTREEraooREss � .�
__ -�I b 1-����� , n� .S� . _
��N ��nn,� �" I,�Y1��7z�'���,� � sr � — ��P �� ��
Tax Payments and Credits: �y
1. Tax Due(Page 2,Line 19) (1) //J
2 Credils/Paymen�s �
A.Pnor Payments .___ _...
B.Discount
. _ _
(See ine�mdlons.) To�el Credt6(A+B� (2)
3. Interest
(3)
4. If Line 2 is greater�han Line 1 +Line 3,enter�he diHerence. This is�he OVERPAVMENT.
Fill in oval on Paga 2,Line 20 to request a refund (4)
5. If line 1 *Line 3 is greater�han Line 2,enter ihe diRerence.This is�he TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
, .._ ,,. ..,:f:.. . .�. ex. _w,.r. ...,d.,.Tc.�i`..�3<rr �-•.-43ir �,°zi�`,«€AF}�s.�. d. , ., _a,..7�.�'�- ".s .a^ �a�ilx.n , :.'€P
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl deceden�make a�2nsfer ana: Yes N���yyyo
a. retain the use or inwme ot Ihe propetlY�rznsferred ....... _. ... ... ❑ �
b. retain the righ��o designate who shall use the propeity iransfened ar ils mcome ... _. ❑
c. retain a reversionary mterest ._._._.. ....... .... ... .... ❑
tl. receive�he promise for hfe of either paymenls,Oenefils or care� .... .... .... ❑
2 If dealh ocwrretl afier Dec. 72, 7982,did deceaenl lrznsfer property within one year of death .
withoutreceivingatlequateconsideration? ............. ............_. .___ ...... ❑ �
3. Did deceden�own an'in trust fof or payable-upon-0eath bank account ar secunty at his or her deatM ...... ❑ �'
4. Did deceden�own an ineividual reliremen�accoun� annuiry or other noo-probate property which ,b.r
contains a heneficiary designahon? .,,.,..,,. ............... .. ............... ...,..,..,.. ............ ❑ /C-J
IF THE ANSWER TO ANY OF THE ABOVE�UESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
... x � .�.a � e .=e . , .'�r . ,.r�,�a�'stt�t�?P,�.v �'i i : ��-.a�v ,P^� �; n� t �:t.� , . .'��' , . .
Por detes o(deeth on or aftar July 1,1994,and before Jen. 1, 1995,Ihe tax ra�e imposed on the net value of trdnsfers to or for Ihe use of Iha surviving spouse
�s a percem p2 P.s.gsns�a��� i)p)].
For dates of death on or aker Jan. 1, 1995, ihe tax rate imposetl on (he net value of Vansfers to or Por Ihe use of�he suniving spouse is 0 percent
p2 P5.§9116(a)(1.1)(ii��.The statute does not exempt a transfer to a surviving spouse from tax,and the staNrory requiremenis for disclosure of assets and
ftling a tax retum are still applica6le even if the surviving spouse is Ne only benefciary.
For dates of death on or afler July 1,2000:
• The tax rate imposed on the net value of transfers fram a deceased child 21 years of age or younger at death to or for lhe use of a natural parent, an
adop�ive parent or a step�parent of�he child is 0 percent[72 P.S.§9116(a)(12)].
. ThetaxretelmposedonthenetvalueofiransferstoorfortheuseofthadecedenfslinealbeneFlcienesls4.5percent,exceptasnotedlnp2P�S.§9116�a)�1)].
. The tax rete imposed on the net value of transfers to or for the use of ihe decedenPs siblings is 12 percent�72 P.S. §911fi(a)�1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parenl in common with Ihe decedent,whether by blood or adoption.
Rev-isoa Ex+ (ia�i�)
� pennsylvania SCHEDULE A
oecaarnervroFaEVEr+ue REAL ESTATE
MHERITPNCE TP%RHL0.N
RESIDFM pFCEDENT
ESTATE OF: � � �� FILE NOM6ER:
I��.�l��lr �-� , � �
pll real prope owne0 solely or a tenant in common must be reporteE at(air market value. Fart market value a OefineE as me vn�e a[wh¢n property
would 6e eachange0 between a wil: g buyerand a wllling selleq nelther being mmpelled m buy or sell, both having reasonable knowledge ofthe relevantfacfs.
Real D�operty that is jointlyrowned wifh right of survivorship must be tlisclaseA on Schetlule F.
NttacM1 a wpV of Ne settlement sheet i`the pmperty has been sold.
ITEM IntluCe a copy of the EeeG showing 4ecedenPs'mteres[if owneG as tenant In common. VHWE AT�ATE
IVUMBER OF�EATM
DESCRIPTION
�. j o u5 e- - ��� r�+� � o u�neaL � ;�-�-, -��: va o;
�j�pD u�.. iy�,? r�[�. �
�
- TOTAL(Also en[er on Line 1, RecapiNlation.) S 3 ���.��
II more space is neetle�,use addicional sheets of paper ot the same size.
REVd5o8 E%+(a&n)
� ` pennsylvania SCNEDULE E
oeannrnervroFaevervue CASH� BANK DEPOSITS & MISC.
�"���a�T^"�E'""aET�"" PERSONAL PROPERTY
aes�oerv-oeceoerv�
ESTATE OF: � � / �,���/ FILE NUMBER:
�i<<frsT � '�
�Intlutle the pmceeds of litigation anG the Oa[e the proceeds were received by the esta[e.
A propertylo���IY owne0 with right of survivarship musf be dis[losed on ScheOule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
� � I �
/ /
� �
� Il,til r7���J 7��12�>-� 1�� l.��n (UlC- � � �� �' �✓
� � v.�� 1
��1�- �161"� �-��r'li5h��� 5 1� ��� • ��
� ��,�i'Yl i��'1,-�,� � � i�,''1'L4 l��`�� �l1 l I eG-��zljlt5
(�-I'��w,nUt —�vww� �
i �
C�,y,�C/t,�� J�CC� C�� � ( �+� ��tin�i7h+ � ��,
/ �L��-� ��,vti� ��i�h �D �t � s� � �05. �
� � 5.��
TOTAL(Also enter on Llne 5, RecapiNlation) $
If more space is neetled, use addi[ional shee[s of paper of the same siie.
Rev-isn Ex. �io-o9)
� pennsylvania SCHEDULE H
oE aa*ME�� f AF�F���E FUNERAL EXPENSES AND
,NhEa„Anc..AxaEr�aN pDMINISTRATIVE COSTS
aesmEnr oEccocrvr
ESTATE 0 � `�N�✓ � ^ �� FILE NUMBER
1
Decetlen s ebts must be reOorteE on ScheOule[.
IiEM
NUMBER �ESCRIPTION AMOUNT
A. FUNERALEHPENSES:
i ��D
� � S �
� �2j1'�'"hGry � �1�
�2/[`I1� �� �.a'�- (�'C`),`%
CtC�✓� ,� �-'i 3�9 �=,
B. ADMINISTRATIVE CO5T5:
1. Peaonal Represen[ative Commissions:
rvame(s)of versonal nepresentati�e(s) __ __
5[reetAOGress . _. _
Ciry State ZIP _ _ _
Year(s)Commisslon Paid:
2 Attorney Fees'. /�
3. Family Exemptlon�. (If deceCenPs aGGress S not the same as datmanPs,attach explanatlon.) g�L� �� , C%
7�
Oaimant __ _._..
Shee[Address
❑ry .. . . _ State ZIP
Rela[ionsh�,p oF Claimant to Deceaent __
4. Probate Fees:
5. Acroun[ant Fees�,
6. Tax Re[urn Greparer Fees',
].
TOTAL(Also enter an Line 9, Recaprtulation) ; ���'��C�
If more space�is neeGeG, use a04i[ional sheets oi OaOer of the same size.
INVENTORY
AGG[STER OF WILLS OF�{��ti�O'�-� l�m� COUNl'Y,PbNNSYLVANIA
COMMONWFALTHOFPENNSYLVAMA i SS
COUNTYOF J fikNumber
PenonalRep2sento[ive(s)ofNeEsfateof J'f/x-����l-1 . / ��G�'C�/ 11��
deceaseQdepose(s)andsay(s)�hattheitunsapptazingin followinginventoryindudcallofllwporsonalassttswhereversiNace
and all ofihe real estam in the Cammonwealth of Pennsylvania oFsaid Decedeut,Nat tAe vafuation placed oppositt eech item ofsaid
imentay represents i�s fair value ns of the daro of the decedmPs death,and that Decedent owned no reai estam ouuide of[he
Canmonwealth ofPennsyfvanie ucepuhat which appears in e meanorandum aUhe end ofthis invenrory.
I reriCy that the sWements made in Nis Lrven-
rory are hue and wrtece 1 understand thet Falu statc- --
menFs haein ero made subject to ihe penahies of
18 Pe.C.S. §4904 relating b unswom Felsificstion ro
aulhorilies.
Alforney— (NmneJ ($vpreme Coimt/D.No f
(Addrus)
(Telephorie)
Ef1� - U6iflE9Cf
'J D ' �' �, � ��
' FIGU MUSTB&TOTALED G�rC)jS •'�frc�•
�:l ��c�Y- J/�Ivc.t. : ' 1' . —
l.Y f��InS� @ �Ib t'���ar� D�JfNNSr„Ps��uh
j�(Q,4� C,��cu�l +�R' 4' � �� �l'3� �/C�� � �
���5 La ' ���� , c����
�
� A �s� . �
� �5 j�yDo� �0
� N�i�c - }'�D/)1C'�, �2�.✓�'�� ctt,c�'eS� efl{I�CtLt�rS,
(_�<-•a"n<-tu-�'Z- P �
� — C,11ec,f<-�' A� a�i�t� 5-I' �v�n�:�-,;� w�W. �� �/-1� 5e$�-�-
� �� n f'��°� �ouse�
LM�� P>�,�
(AnacG addiHonrtl s/�eets as needeA)
TOTAL: �U �
NOTE: TTe Mcmpnnpwn o[ttN eiWe owiic LLe CommanweallM1 of Pe�uuylvenie msy,41h<IttJon of 9s persarol repafenutive incWCe tla velue af�zcA
ium,W buvM fgvru AwuW wl be a�vAeE uio iFe�mai ofNe Invemory. lSre IOPo.C.S§3301@JJ
FormRW-OG nv. 1013.06