HomeMy WebLinkAbout12-07-05
REV.1 sc{) EX l6-CO}
~ OFFiCIAL USE ONLY
COMMONWEALTH OF REV - 1 5 0 0
PENNSYLVANIA
" OEPAR~~~~T2~~VENUE I INHERIT ANCE TAX RETURN I F1 ~M~~-5-':;-~ ;;-,
HARRISBURG, PA 17128-060) IRE SID E N TOE CEO E N T I COUNTY COD~ ~y"-ai- ... ~ NUMEER- - ~
DECEDENT'S NAME (LAST, FiRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
S/ J.... iZ~} C A-rr-lee/N"€' /(,cf - I ~
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
of ? ooS-- mA () 6 10a 0
(IF APPLICABLE) SURVN/ G SPOUSE'S NAME (LAST. FIRST, AND Ml OLE INITI
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~ 1. Original Return
o 4. limited Estate
[Xl 6. Decedent Died Testate (Ailach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dateafdeathafter12-12~2)
o ,. Decedent Maintaineda Living Trust (At1achcopy aiTrusl)
o 10. Spousal Poverty Credit (dale of death be~n 12.31.91 and 1-1-95)
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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o 3. Remainder Return (date afdaath pnor 10 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) {AIlachSchO)
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NAME NlC.K SIl-EiJ
FIRM NAME, (ff Applicable)
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,. Real Estate (Schedule A}
2. Stocks and Bonds (Schlldule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash. Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vi'lcs,iClnsfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total lines 9 & 10)
COMPLETE MAILING ADDRESS
380':; p~".J s-r-
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(2)
(3)
(4)
(5)
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(7)
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(10)
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12. Net Value of Estate (Une B minus Une 11)
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 Tilx (Line 12 minus Line 13)
SEE.INSTRUCTlONS ON REVERSE SIDE FOR APPLICABLE RATES
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
17. Amount or Line 14 taxable at sibJir.g rata
18. Amount of Line 14 taxable at collateral rate
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x .15 (18)
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CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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I OFFICIAL IJSE ONLY
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CITY
;aXT:~~~:~~~in~7: Credits: (1) ~~,-'=:=
2, Credits/Payments
A, Spousal Poverty Credit
B, Prior Payments
C, Discount
Total Credits ( A + B + C ) (2) D
3, Interest'Penalty if applicable
D, Interest
E, Penalty
Total Interest/Penalty ( 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)
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S, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (S)
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A. Enter the interest on the tax due, (5A)
B. Enter the total of Line S + SA. This is the BALANCE DUE. (SBI-;'~::'~V~
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;............",........................,............................................... ." 0
b. retain the right to designate who shall usa 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, 1962, 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? ............'......................................"'.................................................................. 00
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 penallies of perjury, I declare that I have examined this return. including accompanying schedules and statements, aIld 10 tile best of my knowledge and belief, it is true, correct aIld complete,
Dedaration of otlle than personal repIflS9Illabve is based on all information of which preparer has any knowledge.
P S ESPONSIBLE FOR FILING RETURN
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DATE
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A ESS LJ <'/) /J
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE '
19~OL
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. ~9116 (a) (1.1) (i)J.
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. ~116 (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 i
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)J.
The tax rate imposed on the net value of transfers to or for the use of nt's lineal beneficiaries is 4.5% except as noted in 72 P.S. ~9116(1.2) [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% 2 P.S. ~9116(a)(1.3)J. A sibling is defined. under Section 9102, as af
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COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RlETURN
SIDENT CEDENT
ESTATE OF
(J A-rH tel? I JJ if
Include the proceeds of litigation and the date the proceeds were received by the eslaIIl. AM property jointIy-owned wIh the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. W ftC)../OVI It 1?A~L- A a{)u^,~ 203<1.. 2 "3
1.- A- vyl ex. It C Gc) (.J/V T y'S-6 "3. (,8
A"Wl e,L ~ It cu),,' "'< V 0 {9 2 . 5""
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
S;teD
FILE NUMBER
;20 0 S' .- OOP< '37
;3/
L/
ftw1 e~ -f:..I2A
""3 '-/(, 1.. Cl U
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TOTAL (Also enter on line 5, Recapitulation) $ ~7J;ZZ"'1i.~'itr~'
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
(!,4-rHE~/A/e- 5/UiO
Debts of decedent must be reported on Schedule I.
FILE NUMBER
~O oS" 00 d-3 7
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
CO '--1<'- II..) $ 1'(.;1,;<) ee.4L 1+0 YY1 if
7)e-t./ ""~A'1 - c ~uRGH
6 4(,'( ,38
1(,0.00
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
_0 -
City
State _ Zip
Year(s) Commission Paid:
2,
Attorney Fees
-I> -
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
- 0-
City
State _ Zip
Relationship of Claimant to Decedent
4.
Probate Fees
IS. 00
5.
Accountant's Fees
-'-
6.
Tax Return Preparer's Fees
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7,
TOTAL (Also enter on line 9, Recapitulation) $ B" 'IV. 38
REV-1512 EX.. ~.91)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
S, i-8>
FILE NUMBER
~O oS- 00.;2.3 7
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (!
.4 -r 1-1 ~ /2 I 1...J E'
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1. ~~# fF t70UIVTR'1 meAOOWS
::>... ~~-t:t 93 W~sr 5J.oJ.o,t:!.1!F €m5
3 elf.- 11 'tV H(I~ YYJ A ILIa /i?. <?/-l ~ ~
{/ ft:.# 9.r I-I(P~ YY1 A~ol<. (',q.Asr
/()~9. 93
/'/8.00
Y..s-o.oo
/ It../. 00
TOTAL (Also enter on line 10, Recapitulation) $ I 791" 73
REV-1513 EX-+, (9-00)
.'\ . .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. t- O~.1I S 51 I-I!!D I :r "--
t,3<jO 1>e"",Al.co ""1"tLA1t.., Veeo~/w..z; .r3!73
FILE NUMBER
;:?" oS- C?O ~ 3 F
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not listTrustee(s) OF ESTATE
ESTATE OF
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7 L 'I c u;J k> ",,-t..A /..ID Av<.. 0 i l (...1 ~Ik
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t.( AJ~j(j~\ 13u~cl
3 ",) i)o""uOc'D L.-AMf :DIu.. w..(')I2G. & 170/~
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(f/4/c rt<?();v,-,4AJ .()~();tA~Ce! PC"L'fAI)
P't2/~A.I.z:>
i4 {;, 000- 00
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.
/
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
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TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $