HomeMy WebLinkAbout09-02-05
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPl 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN FILE NUMBER
d-L- 05
RESIDENT DECEDENT COUNTY CODE YEAR
05 '-) t""
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NUMBER
0'3- a5 - 00 5 j I - /
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
EVc:.N5 I1A-KY 'r
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
1'-12- /'2 - ~ 7
[)([ 1, Original Return
D 4, Limited Estate
D 6, Decedent Died Testate (Attach copy of Will)
D 9 Litigation Proceeds Received
D 2, Supplemental Return
D 4a, Future Interest Compromise (cale 01 dealh after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy 01 Trusl)
D 10, Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (dale 01 death prior to 12-13-82)
D 5, Federal Estate Tax Return Required
8, Total Number of Safe Deposit Boxes
Election to tax under See, 9113(A) (Attach Sch 0)
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SOCIAL SECURITY NUMBER
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NAME C &, A.J /v1 c COMPLETE MAILING ADDRESS /'":) /Q
FIRM NAME (If ApplICable) ~ 6 L( rs L U IE 1\ I 0 G-i:' f\ a
~ 775t5u,ek, H ,71+-
15:J.3(j
TELEPHONE NUMBE~ /
7J. '1-' 32.1~ 513
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1, Real Estate (Schedule A)
2, Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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3, Closely Held Corporation, Partnership or Sole-Proprietorship
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~Jq. 11) <as
4, Mortgages & Notes Receivable (Schedule D)
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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)
(8)
(,ll, 8SL. ~~
(6)
(7)
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77.(0
9, Funeral Expenses & Administrative Costs (Schedule H)
(9)
(10)
-0---
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)
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\,11 775.?..Y
.
(11)
(12)
(13)
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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)
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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 See, 9116 (a)(1 ,2)
16, Amount of Line 14 taxable at lineal rate
x,O _ (16)
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17, Amount of Line 14 taxable at sibling rate
x ,12 (17)
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x ,15 (18)
-
18, Amount of Line 14 taxable at collateral rate
19, Tax Due
(19)
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20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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)
Total Credits (A + B + C )
(2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + 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)
ZIP /7 c) l/
S. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (S)
A. Enter the interest on the tax due.
B. Enter the total of Line S + SA. This is the BALANCE DUE.
(SA)
(SB)
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
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
c. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
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.
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.
RESPONSIBLE FOR ILlNG RETURN
a.
ADDRESS C, 5 ~ ~1 vz KJ)^. R~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
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ADDRESS
DATE
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 datpo "I rlA"1th nn 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 sta ~ 01 0) J spouse from tax, Clnd the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the sur. LX) ~_ (. (j{)
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APD l;C . ~0
The ta
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For dat'
The tal
or a stE
'om a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
.2)].
The t2
individ
or for the use of the decedent's lineal beneficiaries is 4.S%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)J.
to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an
th the decedent, whether by blood or adoption.
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. REV.\509E~+.11.97) _~
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATEOFa I r
~00[e..1 H t::. \/If..Nj
SCHEDULE F
JOINTLY-OWNED PROPERTY
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
FILE NUMBER
;<005 005~
SURVIVING JOINT TENANT(S) NAME
ADDRESS
REL,ilTIONSHIP TO DECEDENT
,
A.
M A~Y T. b VtJJ.s
054 ~U~ R\o~c <Ro
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SPouse:
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY
ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach '10 OF DATE OF DEATH
NUMBER TENANT JOINT deed for JOintly-held real estate. DATE OF DEATH DECO'S V AWE OF
V AWE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 199~ 1> NC ~k. ~ ~~,lI\~ 51~021.l5g-'f I 0/2, 35'1. Yo 5'06/0 a \ , 111. 2-d
~. fir ICf1J 'fAAl ~k ~fJc,...,~ .srlOd-.q8C"J ~f 3 ~ 3J. 2." 6010 l'iIY.103
~ /'r "15 VOl) KC\M{'-Vl - 1'-/ /b"OI4Z433 /I fD I 'if Sv 6 c 'l~ 580<7. 'L I
'1 {J; /W'b AA({f' ,- SGv~k 1i1V{*M.t1b - DO 5oWo3lf'l"- ~95,lf'H.. 90 So~/l. , , 47, 7/"- fjS'
5 k IqCI3 \)r~ \us ~ t.' pc..\. &."Y\<L - 00 Cj{ -QJxIJ I 7f{3Y ~", 'I sO. 7V !X> % ~ ~ 2'ZS.37
c,. A. i Cf~.:l \X~ fv." NWt~aA ~c!. - 075'0" OC,007 J03rJ. ?-I, O~L42. 5t.\~ I~ : 42015. 7/
1- A Iq~3. tk~~ ~ ~tA.( ~c!. - C>9'-I7,.0005"01.,,1<)"- ~7, 17T. 30 50&\1" , 43. g-8'j.' S'
g. A {9fS ~ (b H CiA a f.) -co/' nve"\ u..-,\1 'OOLf~ -\ <to S ~d...\ . SZ] ,3 Z So~ liD 0 I 7(.<1. I., f.
9 It- J 99:!:> Fec!.~4 ~~;)~~b 31,7/ '0,<1 3"f,c.., Q3, '~/. Yr9 ~% 4f." ~ to. 9 ~
/0 It ''ifJ ~ )()(<..l<\ I,fo/''/ S~cJ- . Go 71.. sh~ 39, z(,t./. 910 50% , q, (, '3 '2. '-Ii'
,
J , A 19q~ AMe"'IC.CV\ t;/ecfrc<- pQ~ - 5 fO sha{'(.~ t2 I, '51. '10 erl ' 10, ~25- ?o
So I),
(L- A Ic,~3 ?sc"" - s-ksJ- - ~ 3 7 'i sh Q.J4!J 020 ~, 503. 'I) S> '1~ : 10 /, ;;1.51. Jy
)"b /Jr I 'I 'I '?;. V ~('"l ~CJ(\ . ':).\cd... ~ 6~ 'I shcv't:..> I 9, ~8'i. 2.'1 50%' 9. ~4<.{. (. "L
/4 ~ tfl~ &rl<-~ ffft Sa."VlllP 'P->ollcl> 6,. (J 00. tn.) 50 04 :J.,5oo.0,)
t6 Jr. ~OGl ~~~A Ct) 10 -/0/770.-(, 511 L.'-{.J 5tl "I,; ~ 5 ~/. 2.:L
TOTAL (Also enter on line 6, Recapitulation) $ (, '3 ~ 8 1 ". ~5'
" f
(If more space IS needed, Insert additional sheets of the same sIze)
REV-1511 EX+ (12-99) .
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
r:Ko &~1
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FILE NUMBER
;)665. 605 k:>
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
f'?(-C-"- Qcncl ...
'-0-
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
State _ 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 '
71 . 0 c)
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ -7'1. 0 i:>
(If more space is needed, insert additional sheets of the same size)
, I
REV.1512 EX + (1.97)
. .
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
\Zo6t!-r<{
j}
r
2v~ fi.L)
FILE NUMBER
;Loo 5" ~ 00 5 .-z....v
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
AMOUNT
/Jc/YV-
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
U-1
H L Vf:..N 5
FILE NUMBER
QOo5~Oo5co
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not ListTrustee(s) OF eSTATE
NUMBER
]
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
~f\~,{ -:p t..VOJ$
JJ./5 HUL:rOIJ 1.0
OAPA.OIJ1. ?)x I D 13q
f>p6U Y2-
/00 6!/
to
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 CO'v1ER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
~:A,,-'1 r:- (. '\! (. tJ ~
J ~ \'5 rlUL/OAJ RD
OPr'<-A0I17, --Pit \ ~ 13']
I CU, ;:{
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
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)