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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
OFFICIAL USE ONLY
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FILE NUMBER
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COUNTY CODE YEAR
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR)
03 - 30 -0/ C>G- /'7-/61"
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate {Attach oopyofWill)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dais of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (dateofdealll between 12-31-91 and 1-1-95)
o 3. Remainder Return (dateo/death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Mach Sch 0)
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NAME
COMPLETE MAILING ADDRESS
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FIRM NAME (If Applicable)
TELEPHONE NUMBER
7- 77~ - 303
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
OFFICIAL USE ONLY
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
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(6)
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(7)
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(8)
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(9)
(10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election 10 tax has not been
made (Schedule J)
(11)
(12)
(13)
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14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O_ (15) ,.,
x.O_ (16) 0
x .12 (17) 0
x .15 (18) d
(19) '"
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
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CITY
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Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Tolal Credits (A+ 8 + C) (2)
3. InteresVPenarly if applicable
D. Interest
E. Penally
TotallnteresVPenally ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
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(5A)
(58)
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
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; Dr......................... ................................. .................
d. receive the promise for life of either payments, benefits or care? ........................ ............................
2. If death occurred after December t2, t 982, 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? .................. . .................... .. ...............................
Yes
................0
.........0
.........0
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........0
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
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DATE
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DATE
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SIGNATURE OF WPARER OTHER THAtllREPRESENTATIVE .
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ADD~S
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For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 39116 (a) (1.1) (i)].
ADDRESS
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For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 39116 (a) (1.1) (ii)).
The statute does not exemot 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 twenty-one 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% [72 P.S. 39tI6(a)(I.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%, except as noted in 72 P.S. 39t16(1.2) [72 P.S. 39116(a)(I)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is t2% [72 P.S. 39tI6(a)(I.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.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
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PA/DP~.s
FILE NUMBER
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ESTATE OF
All property jointly-owned with right of sUNivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
.,2':> ..s#fi'R~S' /J?E T-,L/Ffi ;;rA''''
cs ~,;)9
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TOTAL (Also enter on line 2, Recapitulation) $
(If more space IS needed, lrIsert addItional sheets of the same sIze)
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REV-1508 EX + (1-971
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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EA./D,F~
FILE NUMBER
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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
NUMBER
1.
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DESCRIPTION
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VALUE AT DATE
OF DEATH
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TOTAL (Also enter on line 5. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
/04/..Q./1?
REV.1511EX+(1.97)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EST ATE OF
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Debts of decedent must be reported on Schedule I.
FILE NUMBER
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ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. r /fe/,a: ~,e. - WI; 0 Ph?dAV r",-...p..~ /"-m...
..J312.J of- P';PPr;f ",';',11$
),/ /H-'/?/S. /u~.~ I'>a- p ,,/uc> t!f'
/j. h1oG'TI ;:./#",..- S p:~/6e &. &> '5~' cd 6 o~~l/ . .&;cJ
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.:2 .j' #-.m~S R. C::;""""fll2.,C'..4 ~"-_C'r.lI~_~.s: I .:$ ,,-,~{-. od
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B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (5)
Social Security Number{s) I EIN Number of Personal Representative(s)
Street Address
City Slate Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation)
Claimant r..""""r ,E"",,J,,,,,,,, os @ !)APL",."", ~,rIL.p~
Street Address "b h qZil S"-J_Y ( <:?:).JGf V/pa",,,.4Jf" Rte-
City dV.". ,a/ (I,,~ '&""'41~ p., J'7D9r../ "''"';C Zip J 7/&'7
State I~
Relationship of Claimant to Decedent ('fj . q~ AJ Q!.- Dl'!':;.r--9.i /....~ -3..$7'.>0 ' uti
4. Probate Fees <!-,t/ h1 l},,o/fi>o/J) - 12 "ff' C' 6' ,-,/''''':;'
(4'"!;V .N.~ -'{;;'.oQ
5. Accountanfs Fees J>1fN>"H~", rffF .s;p?/:'";..D
_~ 9-.S1 .w . 4' __~,.# ,(J...., 0.."'"",,,,,,,.18 ~~;;;6
6. Tax Return Preparer's Fees
l11/Hi'd,p'.Sk; Tfir 5 ';,oI'N""~ ~.o(J. &> P
7.
PDa-dPf) 'S G/I"JAJI - /nAP T/"v c: #r.p~ /,A/ Gl
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IPF,/V (!""m6....tp/_..J IJa,. 1';f(:1 /~
TOTAL (Also enter on line 9, Recapitulation) $ //,::r~/./dJ
(If more space Is needed, Insert additional sheets of the same Size)
REV.1513EX+(1.97)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
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NUMBER
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FILE NUMBER
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RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
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NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1.
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ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
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)
March.skl Tax Service J
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GERALD R. "AACHESKI
ESTEU.A F. .....RCHESKI
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Denve', co 10236
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