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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
cQ.L-O>
COUNTY CODE YEAR
DS2J_
NUMBER
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C
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SOCIAL SECURITY NUMBER
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ ~ -
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[B'1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Allach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death belween 12-31-91 and 1-1-95)
o 3. Remainder Return Idate of death prior 1012-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Allach Sch 0)
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NAME
COMPLETE MAILING ADDRESS
1 00 Yt>~ q{f>f\.O
NEw G~f'\(3i:.~1-A(\ID,fA. -l707j))
TELEPHONE NUMBER
in- 17l.l- -3lf>;3
1. Real Estate (Schedule A)
(1)
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2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule EJ
6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(8)
)'80_00 1
v(J;
~bl u.dd
.----
--
t\ ~6.. 400 ~
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(9) L~f&"-l f6e.
(10)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(11)
(12)
(13)
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d- :;'"7l D()" 0D
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
~3, qCO. 00
SEE INSTRUCTIONS ON REVERSE SIDE 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)
x.O_ (16)
x .12 (17)
x .15 (18) 1/J6&o,.OO
(19) :3 t\ ~tt .Ou
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
;U.1.fon 0>
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
Il-t
Ef~\tJ6t:.R.5 LAtJ€
c y () ~k ~L\.~)
f};,
STATE
ZIP
176""20
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
('1Qbb..MJ
Total Credits ( A + B + C ) (2)
3.
Interest/Penalty if applicable
D. Interest
E. Penalty
9"Jun,3n
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(3) ~;L~ 1,'1 q
(4)
4.
Total Interest/Penalty ( D + E )
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
~~.~ 1,tf~
A. Enter the interest on the tax due.
(5)
(5A)
(5B)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
i'd-H, \.~ 94
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
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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.
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
DATE
707LJ
DATE __
b- J- i - 00
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. 99116 (a) (1.1) (i)].
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. 99116 (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 survivin9 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 PS. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's Siblings is 12% [72 P.S. 99116(a)(1.3)J. 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.
REY- U09 EX + 13-81>1
COMMONWEAlTH Of PENNSYlYANIA
INHERITANCE TAX RfTURN
RESIDENr DECEDENT
SCHEDULE F
JOINTlY.OWNED PROPERTY
P {)R \ ~
~. H1PPEN..5TeEI-
I FILE NUMBER
ESTATE OF
Joint tenant(I):
NAME
A. Dp.~ L. A 1<.. Me. G,.. \ ~E
ADDRESS
'1:.D~ 'f"{<.1>Jrr ST. 0
M~vJ Cl.A,.l"\ f!t:.(< ...,,(\)4). \~,
RELATIONSHIP TO DECEDENT
NO rJt ... fllleND
B.
C.
Jointly-owned property:
ITEM LEnER DATE
FOR TOTAL VALUE DECO'S DOLLAR VALUE Of
NUMBER JOINT MADE DESCRIPTION OF PROPERTY Of ASSET % INT. DECEDENT'S INTEREST
TENANT JOINT , I
1. f\ b-~' ~1 ),. t1()l.\.~G. "6 f..~r - II.{ sfR.rtJ6e~5 LAfV6 5~1 ~"7 50% '--P ~I LfrH>. 0 T>
F~Ir:tv ,sw --r;;,;v 5lf1r, joA.Y\ G;.....v~
f G# V ^ ~ - [)3eo g/X)/-<., t:1j ~ fJ
f(\6c; ql1q. -
nAP])
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TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed insert additional sheets of same size)
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REv-1511 EX + (8-86)
~~
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
Please Print or Type
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
Funeral Expenses:
L
B. Administrative Costs:
L Personal Representative Commissions
Social Security Number of Personal Representative:
Year Commissions paid
11
2. Attorney Fees '.!ioO. ]) D
3. Family Exemption
Claimant Relationship
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fees
C. Miscellaneous Expenses:
1.
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of same size)
S SbO. () 0
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT,280601
HARRISBURG, PA 17128-0601
REV-1162 EX( 11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
MYERS ROBERT E
100 YORK ROAD
NEW CUMBERLAND, PA 17070
-------- fold
ESTATE INFORMATION: SSN: 198-22-8188
FILE NUMBER: 2105-0577
DECEDENT NAME: HIPPENSTEEL DORIS R
DATE OF PAYMENT: 06/24/2005
POSTMARK DATE: 06/23/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 12/26/1988
NO. CD 005483
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $8,241.99
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TOTAL AMOUNT PAID:
REMARKS:
CHECK# 5605
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$8,241.99
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS