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Home My WebLink About08-28-15 � 1505611101 REV-1500 EX�oz_��> ,� PA Department of Revenue pennSy�Vd111d OFFiCIAL USE ONLY Bureau of Individual Taxes �"pR'ME��` County Code Year File Number AE�E��E PO BOX 280601 INHERITANCE TAX RETURN Harrisburg,PA 1'71z8-o6oi RESIDENT DECEDENT ?i'� ' � ��1 � � � ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � � / c � dc / :;3, o (� b � l �ia b DecedenYs Last Name Suffix DecedenYs First Name MI � � `�+ 5 � � � � � �- i ne �l (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return p 2. Supplemental Return � 3. Remainder Return(Date of Death Prior to 12-13-82) � 4. Limited Estate C� 4a. Future Interest Compromise(date of � 5. Federal Estate Tax Return Required death after 12-12-82) C� 6. Decedent Died Testate C, 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) a 9. Litigation Proceeds Received R� 10. Spousal Poverty Credit(Date of Death t� 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 T0:�� Name Daytime Telephone Number K q r o � j fl � � f� c �L f S yl Q � ( �7 ? f 6 d 1 �I 2- RCCaIaT��Ef;f1F+NIL.LS 1�C1hJ9_'t" hJ -'� � � � ..+�J �r1 First Line of Address � ^'� �=� :a � I t ,� ,--7 C'� ' �} � 3 � -e � �s h i r e. �,�I. - r.- N , � . - r� � � r,,. Second Line of Address - � . . , �-> � �'-, .? City or Post Office State ZIP Code — ___��—E FILE� O rn > _r_ �� c� o �i CorrespondenYs e-mail address: 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. SIGNATU 1�F PERS N RESPO S�F I�TURu��._ .�� ._ �/ AT(1 // S ._.. AD�DR"ESS � � � �� '!�� /�,.�� 1� _ /70 5 S .._..� SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS � � PLEASE USE ORIGINAL FORM ONLY � Side 1 � 1505611101 15056111�1 J � � 1505611201 REV-1500 EX DecedenYs Social Security Number DecedenYs Name: RECAPITULATION � ^� �� W �- 1. Real Estate(Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. • V 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. • D 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. • � 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . : . . . . . . . . . . . 4. • l/ 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. "/ `� p�• � � � 6. Jointly Owned Property(Schedule F) t".�..'"� Separate Billing Requested . . . . . . . 6. • � 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property D (Schedule G) �;� Separate Billing Requested.. . . . . . . 7. . 8. Total Gross Assets(total Lines 1 through 7). . . . :. . . . . . . . . . . . . . . . . . . . . . . . 8. � ��. �-�'� a__._._.._.__...____..v_._�___�.�..___..._._�R_. ._....._. _._._.�_._._.. __..w _v.._....__...._._�r..-._.___..�._.._.._�.__m__�.__,�.�_ 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . . . . . . . 9. � �j �S. � � 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . . . . . . . . . . . . . 10. . � 11. Totat Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � � 3 S. l.� �` 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. �� ?f� 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. . v 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 at collateral rate X.15 • 18. • 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. • � 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 � 1505611201 15056112�1 J REV-1500 EX Page 3 File Number Decedent's Complete Address: ' � 3 -0� � DECE T'S NAME " ``(�G`--`�(�.� ___��j _ - -- — _ --—-- _ __ -- _ __ ___ STREET DDRESS — ��`J_ �J e.r��,; r�- _ �D�. � __ --- _-- — _-- ___ _ __ _ _ -- � CITY . , STAT ZIP S S �2z.�lGi C�s � u � j � �` � 11� Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) ��) 2. Cretlits/Payments , j �� A.Prior Payments _____�'� . B.Discount Total Credits(A+B) (2) 3. interest (3) 6 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. o-'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 shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � tl. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurretl after Dec.12, 1982,did decedent transfer property within one year of death without receiving atlequate consideration?.............................................................................................................. ❑ � 3. Did decetlent own an"in trust for"or payable-upon-tleath bank account or security at his or her death?.............. ❑ � 4. Did tlecedent own an indivitlual 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. 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 tleath 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 discfosure 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 natura� 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 decedenYs 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 tlecedenYs sibiings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined, under Section 9102,as an indivitlual who has at least one parent in common with the decetlent,whether by blood or adoption. REV-i5o8 EX+(11-io) �� pennsylvania SCHEDULE E � DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT �ESTA OF: FYLE NUNIBER: � r� Ic(�ne �l ��e-�� d �l 3 -03 l � Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivnrship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH -- ya�- y� � ��.�- TOTAL(Also enter on Line 5, Recapitulation) $ aa• �� , If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNER/1L EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS • / � RESIDENT DECEDENT � 1 ESTATE OF FILE NUMBER �� I �T � . ��-I-1-a� �u 3-D� l 9' Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. �� 35 �� B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) -- — � Street Address City ____ State_ ZIP Year(s)Commission Paid:___ 2. Attorney Fees: � 3. family Exemption: (If decedent's address is not the same as claimanYs,attach explanation,) Claimant — - -- �/ Street Address City State ZIP Relationship of Claimant to Decedent _ 4. Probate Fees: � 5. Accountant Fees: � 6. Tax Return Preparer Fees: � 7. TOTAL(Also enter on Line 9, Recapitulation) $ � �S. �o�.• If more space is needed, use additional sheets of paper of the same size.