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Home My WebLink About08-21-15 (2) � 1505611101 REV-1500 EX�°z_ll, . OFFfCIAL USE ONLY PA Department of Revenue pennsylvania oEP�r�EH. .wE�E��E County Code Year Fde Number Bureau ofIndividualTaxes � INHERITANCE TAX RETURN " PO BOX z8o6o1 i Harrisburg,PA i'7128-o6oi RESIDENT DECEDENT � � / � ' �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY • �� `'=��-� �-�-� � � 8 0 � z o I � a� l � 1 �2 z Bgcdedents LaSt,�Vama, • Suffix Decedent's First Name MI . . ,, ,�'.�. ,�; N ,� �� •.l�A-�� (If Applicable)Enter Surviving Spouse's Information Below Spo�se'stast Name Su�x Spouse's First Name MI r ' +, •� .., Spouse's Sociai Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW �+ 1. Original Returi'� ".� ^ O 2. Supplemental Retum Q 3. Remainder Return(Date of Death � _ - ' ``-�' � Prior to 12-13-82) p� 4. I�nited�statg�, p 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required �~ - . •� death after 12-12-82) � (��':6.9ecgderA Died Testate O 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attacti Copy;c�Nill) (Attach Copy of Trust.) C�!9.�j4j�atiprtflrooe�tis 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) C1'� SP D AlT-"'T R�S�Ti�l MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION S�ULD BE DIRECTED T0: • � t ��►� �• � ��. . Name �a ime Tele e . ' ,. c,,;,� Q . � � �w�� F Z� /�?G L 11-,iv �-hlq�rV �� 7� 7 � �o� ;3' 4�f �l . ,, ,, �;�� : � ;_,-, _� . `. •, ,• ` r� , , ' ,Y f��GISTE`IaOF WIi:L�r;�1SE ONLY . ' _. � !--' � � y First Line of Address �� '� �� ... ... � 1f � � '+L o ��v'f'.�/z y � l. !.!�B ,�t?1�-l� ' rv � .� r�, Second Line of Address [n . ... . ` .....r C� � -r7 City or Post Office State ZIP Code ' DATE FILED ��-l� P h� i 1.. �.. pA� � 7 0 ,t �� CorrespondenYs e-mail address: /�l�a�4�Q�• �`�'''� � •��[�O• �� Under penalties of perjury,I declare that I have examined this return,including accompanying schedul s and statements,and to the best of my knowledge and belief, it is true,corcect and complete.Declaration of preparer other than the personal representative]s based on all information of which preparer has any knowledge. SI ATURE OF PER ESP L O ILING ETURN . �� '�C 2O J�S ADD�/ ��T�y �1�� c�• , �!/�!��l�l. r-�' l7D�/ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ' � Side 1 � � 1505611101 � 1505611101 � � 1505611201 REV-1500 EX DecedenYs Social Security Number _ _ DecedenYs Name: RECAPITULATION 1. Real Estate(Schedul�A'�'.'.� . , a '.'. . . . . .. ` • + . • � i1.�'- a a� ; D��• �'� . , ; � �.;1 2. Stocks and Bonds(Schedule B) . .. . . .. . . . . . . . . . .. . . ... .. . .. . . . . . . . .. . . 2. / Q �Q (i> �0 , " � y . � ! /t .� ;� � .� '," , , • " `; � � 3. Closely Held Corporation, Partnership o��ole-Proprietorship(Schedule C) . .. . . 3. �'� �' 'Q•�Tf� 4. Mortgages and Notes Receivable(Schedule D) . . . . .. .. . .. .. .. . . . .. . .. . . . . 4. Q• Q`O 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . ... 5. p • Q (� 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. � �3� D D v• V v` 9. Funeral Expenses and Administrative Costs(Schedule H). .... .. .. . . . . . . . .. . 9. �� /!,p' O D , �Y 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). .. .. . . . . . . . .. . 10. � ��j a��. � 11. Total Deductions(total Lines 9 and 10). . . . . .. .. . . .. . . . . . . . . . . . . . .. . .. .. 11. ��`20�. �Q . , _ �. � ; , 12. Net Value of Estate(Line 8 minus Line 11) . . .. .. . .. . .. . .. .. . . . .. . .. . . ... 12. �� .'�� 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which X � .an e4ection tatax has notbaien.made(Schedule J} �-�-. . . . .,,. .t... .�.. .,� 1�. . �• . . ��;� �• . , . - � , . ...... . . . �� 't .. �. ,.� cr�� , �� ' , "��t �i , � .., � a. 14. Net Value Subject to Tax(Line 1'2 minus Line 13) .. . .. . . . . .. .. . . . . . . . . . . . 14. ' � a �' 77 S• � �' TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 � L �, �-.�' *,,;�'� , ti- �, „� . � �'� � � �� .� � . . - .. . . . , �a)�1.2)X.0- , ',� .�. ;_ • , � _ �., -' . * 15. ..� . �.,, .. ,„s 16. Arriount of Line 14 t xable ' at lineal rate X .0� . 16. � a v "� r-�'�. S v' 17. Amount of Line 14 tax�ble at sibling rate X.12 .�' 17. `� :° 18. Amount of Line 14 taxabie ,:. � �, � '.� � � �� , ;�� , � ��` , aC collateral rate X.15 ��' � � � � ,- , • �_ 18. ' ` - � �� -• : x � . �� rf�� . 19. TAX DUE . . . .. . : �t:'''. . r.�. .. . .5'_. . � -� c. � % '��a��_ ��: . ,� _ ��`s, . . .`t+�'`��' �s.-r.,� '� ��.=f �-- . 1-��.• - � , - , , _.. . _ . ,20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAY'MENT • p � ;f` • � ."` ` ' • - ' . � � • . � . i ' , ,'` ' . • "„ . . 3.;F'.: t ` �_ � , '. .e '� _ ��,', � ' . ` . i R , '� " .� .'�• � ,' Side 2 � 1505611201 1505611201 � REV-1511 EX+ (10-09) � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER TPan � ulinP ��ln—��9�7 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. a. �3urial Plot ?�Q5 • �� b. Inter*�ent Fee 1, 045. 00 c. Cremation 1 . 795 . 00 d. Urn 520 . 00 e. Post funeral �� • �� f. Minister 100 . 00 B, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s)_ Street Address City ___ State _____-_ZIP _ Year(s)Commission Paid: 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: �O�� 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ �Q��Q If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) � pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER q�ean s l�,�l/1e... �OI�-- DOg57 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �. Gt,�i1�P f�/�G ��2 ,�3/L L- :� ��f, S4 ,��v �,��z� �,�'�, da ,�-. L-� . . �� 19�- . 3 . �/p��'o�v�v�'/zs �su��-'r�- . fa�, ��" �. �� I1/��rs�-�. . . ,�so . °° �; w��,�- ��- � ,�� f��. /7� • O° � g93� . �o � ��,��r�" 6� �� ' . � �oi� �- . G��,�- �ir�-s �Z�ZS/�'ler�o �t /'i oa.� - � �'va c�l /� �v - °-J �oo� � c�/l"S �2„�Z� /�I�r�o� � . � , � ,�� TOTAL(Also enter on Line 10, Recapitulation) � If more space is needed,insert additional sheets of the same size. REV-1513 EX+ (01-10) � pennsylvania SCHEDULE � � DEPARTMENT OFREVENUE � INHERITANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT ESTATE F: . PILE NUMBER: e.an s'. �:.� � a�f�r-oo�'�7 RELATIONSHIPTO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116(a) (1.2).] 1 DD �t-uec �.!'�'I�.Ca.,►a� a � � �on �23/� ODO. h�/ L�ou�f-�j. Lr/u,� /f�a �j� y;��, l�a. � �_ �� d� ,► v �. �� . /1'II�'1-�/�a�n ac� h�'' , 9 �f�r �ou,vT�y��ua /?e,�01 /a.��fi C��,o �`i/, �'.�— • ° ° Q ,-�� /�� . �l��o� �? ryI- .C�� 11 G�ou��-y Gylu,6 R�-- Lj,��, i�.�/% �a— �orl ��3�0, sv �/. ��r�„�G. /rI�'LAna�a� �' ,�o��h ��r o�a r�/ . ��O � i �+� h a�i,a�'I ��„�lLc�`l � �/eXa��h Z� ST / .� ENiF��'10UN7SFOR DI�TRI TI�S 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: L 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,use additional sheets of paper of the same size. REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STR E AD RESS - /1 �Q � � � 1�/LL CITY STATE ^� I ZIP f �O f� �J Tax Payments and Credits: 2 / pp 1. Tax Due(Page 2,Line 19) (1) � �J(v � 2. Credits/Payments A.Prior Payments B.Discount D . �v Total Credits(A+B) (2) 3. Interest v �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. . �� n ✓.'M1:�� ,�r G�, y". � k;�i -... "�� '�n'��X"�. ys�� .* '�' . �w`�. =A- a y,�"�r::e.� 5km � :: ,� y �.;�, ,.,:c....-,.t��rs. .,�.v.m-..a .:, , `" �,�' r.s�`-�""�?,��da^vra.� :.�,-`.�' M.�``�x1.ws,. :� -`.. .xd4�� ,n .. � � .,�'.s�'m��°,. ,L."...ek� �.,-�.�7_. �.x`.�,G.s�.d:.�X.i�.� r..�`��=:: 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 transferretl.......................................................................................... ❑ � b. retain the right to designate who shail 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?.............................................................................................................. ❑ L�✓J,/ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ Ita 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. �r*� + �.�� ` ��r_- �' xn .r � ��^ :�� "`" .��,�� '`��se��>s�"��"``t� ��.i�? ,��5 ��v�`r� ��,��"�',4_ ;�� "�J ��"�;��'' .^ a- =r p -, , „ .�. �.,.,s�:^1`rv��=�ii.� -. _ �s�,f,�� =�.x,� �w�: :�.� ,., _„x �-a.�•�.��. �e..._,.�an;�.s . .�`:a.�.�,�_. �S��a� �F . �.s _ ✓,�" �.r For dates of death on or after July 1, 1994,antl 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 tlates of death on or after July 1,2000: � . The tax rate imposed on the net value of transfers from a deceased chiltl 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 chiltl 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 lineai 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 tlefined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. ,