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Home My WebLink About06-17-05 REV-1500EXI6-00i . REV-1500 OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT 280601 aL-fl5 OO~'8j HARRISBURG, PA 17128-0601 RESIDENT DECEDENT COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- FREET YAUl.iAli;. E- 117 - .10 - J(, 7~ z W DATE OF DEATH (MM-DO-YEAR) OATE OF BIRTH (MM-DD-YEAR) C THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W 03 If :/'00:) 05.2.3 I'll$' REGISTER OF WILLS U W (IF APPL CABL ) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C }III - - w !Zl1. Original Return o 2, Supplernental Return o 3, Remainder Return (date of death prior to 12-13-82) ..., ~~U) o 4. limited Estate D 4a. Future Interest Compromise (date of death after 12-12-82) o 5. Federal Estate Tax Return Required u"'''' w"-u :rOO 1:&1 6. Decedent Died Testate (Mach copy afWill) o 7. Decedent Maintained a living Trust (Atlach copy oITrust) 8. Total Number of Safe Deposit Boxes u"'~ ,,-Ill ~ "- D 9. litigation Proceeds Received o 10. Spousal Poverty Credit (date of death oetween 12.31-91 and 1-1-95) o 11, Election to tax under Sec, 9113(A) {Attach Sch 0) '" ..., z w NAMES. ftEET COMPLETE MAILING ADDRESS " z 1/./ J' A Allc. 0 CiJ/,U#f 8v,S' "- FIRM NAME (If AppliC8ble) //31. ., AlA w '" fA-. '" TELEPHONE NUMBER /..","~Y4leJ J7tJ "3 0 717- 7(,/- J.3&'1 u 1. Real Estate (Schedule A) (1) .00 e:.FFlciill. USE ONLY "" ("') = = ::1") 2. Stocks and Bonds (Schedule B) (2) ,()U ~O c.n reI :U:n '- C~) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) .00 i-'n "'Uo c: C) :1J~ r- r- __::u 4, Mortgages & Notes Receivable (Schedule D) (4) ,OU C- m - C') .,~w:X'J N rrl C) 02,)13. 3.3 ''4 ^ 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) -'00 -0 C) (Schedule E) :-JO .1 -'";"1 Z (-,,--- ::Il: ...,., 0 ,()O ~~55 ~ (;'''5 ~ 6. Jointly Owned Property (Schedule F) (6) CD"'" rn D Separate Billing Requested p ... (1'") (:::) '-;>'1 ...I ,dO 0 ::J 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) !::: (Schedule G or L) D.. :l.. ~7J.JJ <( 8. Total Gross Assets (total Lines 1-7) (8) U , W 9 Funeral Expenses & Administrative Costs (Schedule H) (9) . dO c::: .p :2./ , fl 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) (11) ,2,3.2/,1'/ , + 12 Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) - made (Schedule J) 14 Net Value Subject to Tax (Line 12 minus Line 13) (14) {} SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax 0 .00 !;( rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15) I-' 16. Amount of Line 14 taxable at lineal rate '0_ (16) ,(JO ::J D.. 17. Amount of Line 14 taxable at sibling rate x .12 (17) ,UO ::iii 0 18. Amount of Line 14 taxable at collateral rate x .15 (18) .Ou U X 19. Tax Due (19) ,VO ~ 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: ,c. hen' STREET ADDRESS ,. J IIJ.. IPALAlt/r HM,l/rUAI-D HQA1f CITY 4i~ ISJ..I: ZIP 17()/ 3 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) -()-- 2, Credits/Payments A, Spousal Poverty Cledit B. Prior Payments C. Discount Total Credits (A + B + C ) (2) -{j- 3. InteresVPenally if applicable D. Interest E, Penalty TotallnteresVPenalty ( D + E ) (3) lJ 4. If Une 2 is greater than Une 1 + Une 3, enter the difference, This IS the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference, This is the TAX DUE. (5) A. Enter the Interest on the tax due. (5A) B. Enter the total of Une 5 + 5A This is the BALANCE DUE. (5B) -#- 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;.. . 0 ~ b. retain the right to designate who shall use the property transferred or its income: .... .... 0 [B G. 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 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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, correel and complete Declaration of pre parer olherthan Ihe personal representative is based on all information 01 which preparer has any knowledge SIGNA~. F !,ERS~~NSI~R FILING RETURN DATE ~ .9 cd,". . //. ~~7" .-;- ADDRESS ~ //:<'1; ~--o~__.6",~ ~R.. L~_..-tDT"'''- - 1701--3 SIGNATURE OF PRE PARER OTHER THAN REPRESENl1..TIVE ' DATE ADDRESS 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 PS ~9116 (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 tOI the use of the surviving spouse Is 0% [72 P.S. ~9116 (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. ~9116(a)(1.2)], The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneflclalies is 4.5%, except as noted in 72 P,S. ~9116(1.2) 172 P.S. ~9116(a)(1)J, The tax rate imposed on the net value of tlansfers to or for the use of the decedent's siblings Is 12% [72 P,S. ~9116(a)(1.3)], A sibling is defined, under Section 9102, as anœindividual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) . - SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ . FilE NUMBER /;.~ ft.U{ .AIJ.."JE All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. N"Q~ - TOTAL (Also enter on line 1. Recapitulation) $ (If more space IS needed, insert additional sheets of the same size) R~V.1503,IX+(1-9~) '* SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF~ . !kul" FilE NUMBER E "J/()J..wf All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. rJ ~U[ TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~"""'I''''.* SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN PARTNERSHIP or SOLE-PROPRIETORSHIP RESIDENT DECEDENT I ESTATEO~ . ~cer FilE NUMBER /9Vt./d/t ,E. Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporationfpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. tJ opt TOTAL (Also enter on line 3, Recapitulation) $ (If more space IS needed, Insert additional sheets of the same size) REV.1505EX + (1.97) '* SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF '/2 FilE NUMBER /4//J../J/C J:. ;=; PET' 1. Name of Corporation IlJ f}IJ E State of Incorporation Address Date of Incorporation City State Zip Code T otai Number of Shareholders 2. Federal Empioyer 1.0. Number Business Reporting Year 3. Type of Business ProducVService 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I Non.Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? o Yes o No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? DYes o No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? DYes o No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes o No If yes, o Transfer o Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholders agreement in effect at the time of the decedent's death? DYes o No If yes, provide a copy of the agreement 10. Was the decedent's stock sold? DYes o No if yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? DYes o No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? DYes o No If yes, report the necessary Infonmation on a separate sheet, including a Schedule C-1 or C-2 for each interest A Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Fonm 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market valueJs. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. REV-15G6 EX+ (9~00) .., '* SCHEDULE C-2 PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF 12 FilE NUMBER / ~ /J LII}ff t=:. hUT . 1. Name of Partnership Date Business Commenced Address JJOAl~ Business Reporting Year City State Zip Code 2. Federal Employer 1.0. Number 3. Type of Business Product/Service 4. Decedent was a o General o Limited partner. jf decedent was a limited partner, provide initial investment $ 5. A. B. c. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ............................... o Ves o No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ... 0 Ves o No If yes, Cash Surrender Value $ Net proceeds payable $ _ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? o Ves o No If yes, o Transfer o Sale Percentage transferred/sold _. Transferee or Purchaser Consideration $ Date -"-- Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? o Ves ONo If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ......... ....... ...... .... o Ves ONo If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................ o Ves o No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .... ........... .............. o Ves o No If yes, explain____ ________________________ 14. Did the partnership have an interest in other corporations or partnershIps? . . . . . . o Ves o No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/so If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. ~EV~'507 ~X+ (1-97) '* SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF ~ . FilE NUMBER E Fiar 1/ L.lu i All properly jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. N{)/Jt TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 'EV:,"O","""'.. SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATEOF~ . . hEE'l FilE NUMBER !JVJ./pt ,c. 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. tJRtfldv,'/f CL.uh 50 CHE~lI.jP(, J 27"3.33 J *- 10110 31~ $11 ~ If TOTAL (Also enter on line 5, Recapitulation) $ .;. ,!l73.H (If more space is needed, insert additional sheets of the same size) R~.1509p::+(1-9:) '* SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTL Y.OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF "~VI..IU~ FILE NUMBER ,.f. r/lFecr If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. /111/.) E B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY . %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Atloch DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deedforjointiy-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) $ (If more space IS needed, insert additional sheets of the same size) REV-1S10 EX + (1.97) *' SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA MISC. NON-PROBATE PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~/II..'UI! hUT FILE NUMBER .J;. This schedule must be completed and fried if the answer to any of questions 11hrough 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENTA NDTHEDATEOFTRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH ACOPYOF THE OEEO FORREALESTATE. VALUE OF ASSET INTEREST IF APPLICABLE) NUMBER 1. J~P/!. TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) REV-1511 EX+ (12-99) . ~~ SCHEDULE H , '!:of COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF e () '-iAi E fiuEr FilE NUMBER ..E. Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ;tJA B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/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 claimant's, attach explanation) Claimant Street Address City _ State __ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) RE\,I-1512E'>:>(1_9Ij ~ ~ SCHEDULE I COMMON'~ALTH OF PE~NSYLVAN'A DEBTS OF DECEDENT, INH~~~;~~~io':2E~~~~RN MORTGAGE LIABILITIES, & LIENS ESTATE OF ":} . FILE NUMBER !/:J/JJ../~( C. hUff Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 7HDI{/.)WIILIJ J-I~M~ r1 A Jt. f'/ } ~ )~ liliEs 1/.iItJ 3, RtVJs'U( of bJ:LI.S 7Jf. DO TOTAL (Also enleron line 10, Recapitulation) $ cZl 32/. 5f (If more space is needed, insert additional sheets of the same size) . REV:'5'~ EX. (9-00~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~/J/..I"vi Filur FILE NUMBER ;:, RELATIONSHIP TO 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. iJ); /...4I.D k FflEeT) ;T1l. S...) 33 ~ /3/ !lAI.WD"I> ellte,E- , J(i lJ. ,"",,""tt,. h 3'17Y'I l. Rud-A tJlfVI( r ,,/I j)I9VtJJ(T~1I. "H~ J. 'II HUIII( L.A ILl< }?1Al) hU.N II... jJ tJ ilK, AI. X O'lt3l. 3. S'4/1,4 A. F~EEr fOil,.,'" L~a .r~".4 ().)(V~./lo j)" v6-N Tei< 31 J.J ~ JUt. t,I.II,.,/lwt /lilt. ).lil11ljAl~ fA, 171'13 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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. 1A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ,. flIJ TOTAL OF PART 11- 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) '''''~'''~'''I'''". SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN & TERM CERTAIN RESIDENT DECEDENT Check Box 4 on Rev-1500 Cover Sheet ESTATE OF 'PAUJ..,,,;e J:. FILE NUMBER rnUr This schedule is to be used for all single life, joint or. successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax retum. o Will o Intervivos Deed of Trust o Other LIFE ESTATE INTEREST CALCULATION NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE ^, . ,,; o Life or 0 Term of Years f' ." o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years _ 1. Value of fund from which life estate is payable $ 2. Actuarial factor per appropriate table I nterest table rate - 031/2% 06% 010% o Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) $ ANNOITYINTERESTCALCOLATION NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUIT ANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE o Life or 0 Term of Years _ o Life or 0 Term of Years _ o Life or 0 Term of Years _ o Life or 0 Term of Years 1. Value of fund from which annuity is payable $ 2. Check appropriate block below and enter corresponding (number) Frequency of payout- o Weekly (52) OBi-weekly (26) o Monthly (12) o Quarterly (4) o Semi-annually (2) o Annually (1) o Other ( } 3. Amount of payout per period $ 4. Aggregate annual payment, Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) I nterest table rate 031/2% 06% 010% o Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity. If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is : Line 4 x Line 5 x Line 6 $ If using variable rate and period payout is at beginning of period, calculation is : (Line 4 x Line 5 x Line 6) + Line 3 $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If more space is needed, insert additional sheets of the same size) REV-1644 EX+ (3-84) INHERITANCE TAX ~~ SCHEDULE "L" COMMONWEALTH OF PENNSYLVAN,A REMAINDER PREPAYMENT OR INVASION INHERITANCE TAX RETURN RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER I. Estate of (iR E/!-r fAUl..iv E" E. (lasl Name) (First Name) (Middle Initial) This schedule is appropriate only for estotes of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when on election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. Remainder Prepayment: /hA/E A. Election to prepay filed with the Register of Wills on (attach copy of election) (Date) B. Name(s) of life Tenant(s) Date of Bi rth Age on date Term of years income or Annuitant(s) of election or onnuity is payable C. Assets: Complete Schedule L- 1 1. Real Estate S 2. Stocks and Bonds S 3. Closely Held Sfock/Parfnership S 4. Mortgages and Notes S 5. Cash/Misc. Personal Property S 6. Total from Schedule L-l S D. Credits: Complete Schedule L-2 1. Unpaid liabilities S 2. Unpaid Bequests S 3. Value of Unincludable Assets S 4. Total from Schedule L-2 S E. Total value of trust assets (Line C-6 minus line 0-4) S 4 F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x line F) S (Also enter on line 7, Recapitulation) III. Invasion of Corpus: A. Invasion of corpus (Month. Ooy, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus consumed or onnuity is payable C. Corpus consumed S D. Remainder factor (see Table I or Table II in Instruction Booklet) S E. Toxable value of corpus consumed (Line C x Line 0) S (Also enter on line 7, Recapitulation) REY.1645 EX+ (7-85) INHERITANCE TAX ., .. SCHEDULE L-l COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION ,NHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER .. Estate of FRE~r ~ULllUd 6: (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Esfote (please describe) JJ, !:!-~ Total value of real estate S (include on Section II, Line C- 1 on Schedule L) B. Sfocks ond Bonds (pleose list) Total volue of stocks ond bonds S (include on Section II, line C-2 on Schedule l) C. Closely Held Stock/Portnership (ottoch Schedule C-1 ond/or C-2) (please list) Total value of Closely Held/Partnership S (include on Section II, Line C.3 on Schedule l) D. Mortgages and Notes (please list) Total value of Mortgages and Notes S (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (pleose list) Total value of Cash/Misc. Pers. Property S (include on Section II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, Line C.6 on Schedule L) S (If more space is needed, attach additional av, x 11 sheets.) REV-1646 EX+ (3-84) INHERITANCE TAX * SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -CREDITS- FilE NUMBER I. Estate of fflCI!T l.UJ..IUE t=. (lost Name) (First Nome) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule l- 1 (please listl AJ'J/~ --- Total unpaid liabilities S (include on Section II, Line D-l on Schedule l) B. Unpaid Bequests payable from assets reported on Schedule l-1 (please list) Total unpaid bequests S (include on Secfion II, Line D-2 on Schedule l) C. Value of assets reported on Schedule l-1 (of her than unpaid bequests listed under liB" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unindudable assets S (include on Section II, Line D-3 on Schedule l) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) S (If more space is needed, attach additional 8% x 11 sheets.) RE.V-16~7 EX+ (9.0,* SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4a on Rev-1500 Cover Sheet ESTATE OF ~UL.u)f FiLE NUMBER l Faar This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. 0 Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. I I), 2. '/'t 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. 0 Unlimited right of withdrawal 0 Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest.........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also Include as part of total shown on Line 13 of Cover Sheet) .... ..$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One 06%, 03%, o 00/0......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One 06%, o 4.50/0 .......................,...$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) RE~-'64~ EX (l92) . SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLANIA INHERITANCE TAX DIVISION AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91. ESTATE Of E .' I filE NUMBER i1UJ.'/.Jr .E hce"- This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE 1. Taxable Assets tatal Iram line 8 (caver sheetl........~................................................... 1. 2. Insurance Proceeds on Life of Decedent ............................................................................ 2. 3. Retirement Benefits.......... ................................................. ............ ............................... 3. 4. Joint Assets with Spouse... .................................. .......... ............................. ........... 4. 5. PA Lottery Winnings .......... ................................. ......................... ..................... ......... 5. 60. Other Nontaxable Assets: List (Attach schedule if necessary).. 60. 6b. 6<. 6d. 6. SUBTOTAL (lines 6a, b. e, dl.......... .......... ...................... ....... ........................ ........... 6. 7. Total Gross Assets (Add lines 1 thru 6)..... ......... ............ .......... ................... ................. 7. 8. Total Actual Liabilities ..................................... ...................... ........ .. ............................. 8. 9. Net Value of Estate (Subtract line 8 from line 7)............................... ................................ 9. If line 9 is greater than $200,000. STOP The estate is not eligible to claim the credif If not continue to Port II PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax Returns for decedent and spouse.) Income: 1. TAX YEAR, 19 2. TAX YEAR, 19 3. TAX YEAR, 19 o. Spouse .......... .......... la. 2a. 3a. b. Decedent ........ .......... lb. 2b. 3b. c. Joint .... .......... .......... Ie. 2e. 3<. d. Tax Exempt Income..... Id. 2d. 3d. e. Other Income not listed above ........... Ie. 2.. 3e. f. TataL................. ....... If. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (If) + (21) + (311 = (+ 31 4b. Average Joint Exemption Income .................................................... ..................... .......... = --- If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part III. PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT EST A TES 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less....... ........ .... 1. 2. Multiply by credit percentage (see instructions) ............................................... .......... ....... 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of toto I credits on line 18 of the cover sheef. ..................... ...... ....... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate... ..... ..... ............................ .... ........................ ..... ...... ........... . ..... 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. 5. REV.164?EX.!i-97) '*' SCHEDULE 0 ELECTION UNDER SEC. 9113(A) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATEOF~ hltEr FilE NUMBER K /WLIIJE Do not complete this schedule unless the estate is making the election to tax .asets under Section 9113(A) ofthe Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferols personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arranQement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arranQement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement DESCRIPTION VALUE ~ Part A Total $ PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made. DESCRIPTION VALUE Part B Total $ (If more space is needed, insert additional sheets of the same size)