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Home My WebLink About08-13-15 1505611101 REV-1500 Ext°z_"' 71 lvania Bu ENN ME enns OFFICIAL USE ONLY Department of Revenue PY Bureau of Individual Taxes `p`VEN E County Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN Tq]751-]Harrisburg,PA 1'7128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social -Security Number Date of Death MMD;D�YYYY Date of Birth �MMDDYYYY ��o!v31�ol JC7J 'Z Decedent's Last Name Suffix Decedent's First Name MI t�- i��!Ji� �UC� ��i� `��JIU�I�UCIC�� C� (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI f9z `m w_ii U_C-J- 011 CU's a�l w <a� , Oar I Spouse's Social Security,Number� -1 THIS RETURN MUST BE LED IN DUPLICATE WITH THE �iREGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW iM 1.Original Return Q 2.Supplemental Return Q 3. Remainder Return(Date of Death Prior to 12-13-82) Q 4. Limited Estate Q 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) O 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.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number lsai►'!'. ;I� �,! _-171��o • I REGISTER OF WILLS USE ONLY ry First Line of Address Second Line of Address _ M = n � ioIng l�� +W ��I�I I' —�1n T r— F-� M 0 _m I _J�_ ��4 J'J�.�!-11�t�rUlJI,J'T.0' i D_ C A'f�t FILED City or Post Office _ _ State ZIP Code__ _ Tt r � 1 LUP JI3�raI`-� L � C- CO -i r- 0 Correspondent's e-mail address: Cf J _T1 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 than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSONPONSIBLE FOR FILING RETURN DATE \Jho. ADDR S SIGNATURE OF PREPARER OTHER THAN REPRES'1=- TATIVE 1 DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611101 1505611101 J 1505611201 REV-1500 EX Decedent's Social Security Number / Decedent's Name: ,�� fl 1 V-1 e- RECAPITULATION 1. Real Estate(Schedule A). .. .. .. . .. .. .. . .. . . .. . .. . . . ... . ... .. .... . . ... 1. 2. Stocks and Bonds(Schedule B) . . ... .. . . .. . . .. . . ... .. . . ... . ... . ... . .. . 2. t -7 01 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. • 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. t -7 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. f/ 12. Net Value of Estate(Line 8 minus Line 11) .. . .. . . .. . . .. .. ... .. . . ... .. .. . 12. t 7 7 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. w q . a 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 at collateral rate X.15 0 18. • 19. TAX DUE . .. . .... .. .. .. . . .. . .. . . .. . .. .. .. . . ... . . .. .. .. .. . . .. . .. .. . 19. r 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O r Side 2 1505611201 1505611201 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STREET ADDRESS 3 QPI,%t o cirY sr� Zi a z� 17 3 a Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 2. Credits/Payments A.Prior Payments B.Discount 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 No a. retain the use or income of the property transferred.......................................................................................... ❑ ❑ 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?...................................................................... ❑ ❑ 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 containsa 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(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-1503 EX+(8-12) W NO, Pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF \ t (' FILE NUMBER All property jointly own6d with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on Line 2, Recapitulation) $ If more space is needed, insert additional sheets of the same size