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Home My WebLink About12-14-05 REV.l500EX (6-QO) REV-1500 OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 ~L-.t2:L t1 f-ei-O _ HARRISBURG, PA 17128-0601 RESIDENT DECEDENT COUNTY CODE YEAR NUMB DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) .... Z W THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C W REGISTER OF WILLS (,,) W SOCIAL SECURITY NUMBER C t-Z- /~Z- 1- l!! ~ 1. Original Return o 2. Supplemental Return o 3. Remainder Return (dale of death prior to 12.13-62) .::.l::~cn 4. limited Estate o 4a. Future Interest Compromise (dale of death after 12-12-82) o 5. Federal Estate Tax Return Required u"'''' w"u :cOO o 6. Decedent Died Testate (AlIachcopyofWill) o 7. Decedent Maintained a living Trust (Allach copy of Trusl) -dl-8. Total Number of Safe Deposit Boxes u"'... ..", .. o 9. Litigation Proceeds Received o 10. Spousal Poverty Credit (dale ofl1ealh between 12-31.91 and 1-1-95) o 11. Election to tax under Sec. 9113(A) (Attach Sctl 0) " COMPLETEMAIlING~ES4 #13 .3/'7 21!--~ ' ~ ~ Akfll ~.?/P(,&~7{/AM/ ~ /~;:b ~ - 'JeJ 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) "" C) ~.:J (:.~ (3) I (=~O c.n 3. CloseJy Held Corporation, Partnership or Sole-Proprietorship CJ <.:0 ro' -- ,c) '. 4. Mortgages & Notes Receivable (Schedule D) (4) '1-"1-0 " ~~~ ~. :::;:-.:; - 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) ,-,-<0:: ... (Schedu", E) ,..} '/"'- Z ,---,...-, !:': 0 6. Jointly Owned Property (Schedule F) (6) 12)A - - ~ o Separate Billing Requested :-':_~ ~~D 5 7. In1er-Vivos Transfers & Mfscellaneous Non-Probate Property (7) ./ Ot!) '" ::3 , .... (Schedule G or L) ii: ,...." c( 8. Total Gross Assets (total Lines 1-7) (8) ~ /.~ 1 (,,) 9. Funeral Expenses & Administrative Costs (Schedule H) (g) /7'1 /'7 ~ w c::: 10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule l) (10) 7-2.-,' fJ'C; / 11. Total Deductions (total Lines 9 & 10) (11) ~z:~; 12. Net Value of Estate (Line 8 minus Line 11) (12) (' ) . 13. Charitable and Governmental BequestsfSec 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) ( U/~t/>? ) . SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount ofUne 14 taxable at the spousal tax 0 rate, or transfers under Sec. 9116 (a)(1.2) '.0_ (15) -~- 1< ... 16. Amount of Line 14 taxable at lineal rate '.0_ (16) ::3 D.. 17. Amount of Une 14 taxable at sibling rate x .12 (17) :::E 0 18. Amount of line 14 taxable at collateral rate x .15 (18) (,,) ~ 19. Tax Due (19) -0;>- 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDR SS CITY Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) -0- 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A+ B + C) (2) -cJ'- 3. InleresUPenally if applicable D. Interest E. Penally TotallnleresUPenal1y ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Line 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 Ihan Line 2, enter the difference. This is the TAX DUE. (5) -CJl- 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 8. retain the use or income of the property transferred;.. ...no........... ............................"... ................................... 0 rg! b. retain the right 10 designate who shall use Ihe property transferred or its income; ..... ...................................... D I c. retain a reversionary interest; or................. ..........". ................. ............................... ........".............. ............. 0 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 trusl for" or payable upon death bank account or security at his or her dealh?............. D 4. Did decedenl own an Individual Retirement Account, annuily, or other non-probate property which contains a beneficiary designation? ....... .............. ............................................N D 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 perjuf'j, I declare \hat I ha~e examined thffi retuTn. including accompanying schedules ana slalements, and to lI1e best 01 my knowledge and belief, it is true, correct and complete. Dedaration ofpreparerolherth8n the personal esentative is based on all information of which preparer has any knowledge. IB FORFI RETURN - For dates of death on or after July 1, 1994 and before January 1, 1995, Ihe tax rate imposed on the net value ollransfers to or for the use of the surviving spouse is 3% [72 P.S. !l9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, Ihe tax rate imposed on the net value of iransfers to or for the use of the surviving spouse is 0% [72 P.S. !l9116 (a) (1.1) (ii)]. The statute does not examot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and ftling 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. !l9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for Ihe use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. !l9116(1.2) [72 P.S. !l9116(a)(1)J. The tax rate imposed on the net value of lransfers to or for the use of the decedent's siblings is 12% [72 P.S. !l9116(a)(1.3)]. 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. -c;1 REV""".'''''. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER H/f-I'/ If. -=VV":'~r'7f 2/-I':1S-:" CJ1/a Indude the pRK:eeds of litigation and the date the proceeds were received by the estate. AU property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. I"f'f?-~#, ~~T/1?1T14-~-ef1 cOoAI' - .31'~0t!J ;;... 1'111- /-Ij/lJ5CN/tf/1-(L~7<. -r4 ~d 8"'ao .,3. /1<?.s-:.~((j S/()~~f?&NCCJ ?-1100 "i 5'#~ ~/V5~PC:-T7c7d /~4 /,CiO ...., ,..,v.c=-.w C:::U'H ~4' " Pc:: tI--S;1I//N~ Ikc:r .6, /l(c::-~. ~'7:;z-f?1"f5 7-f~-- t. /ltJf /,/l/.c->5 ...LA/~##--:' ck,c-.?VT- c::::#:~/ ~~ ( /;4;t("uY>~:Zt4115) TOTAL (Also enter on line 5, Recapitulation) $ <;?;O ~~ (If more space is needed, insert additionai sheets of Ihe same size) REV."'''''_I'." '* SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA MISC. NON.PROBATE PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER UA-i< k JJ, <:#/~ h~-~ Z / - tf .:>-- (19'/11 , I This schedule must be completed and filed if the answer to any of questions 1 through 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 DECEOENT AND THE DATE OF TRANSI'ER DATE OF DEATH OECD'S EXCLUSI~~ TAXABLE VALUE ATTACH A COPY OFTHE DEEO FOR R&J.. ESTATE. NUMBER VALUE OF ASSET INTEREST IIFAPPLICABLE 1. /J/7;v/!;'V{ P1k3""7/i1"'.e-/C/6- ,/c;10' /C'c!> -($>- /C7C!J ~~~~. ~~-&/~~/~~~ ( Voy;.1p._..-/f,r-?O,,4d-S) TOTAL (Also enter on line 7, Recapitulation) $ /0& (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) _ . SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF f FILE NUMBER 41l~ ;(, c;-;-€ ~~---,I( -;;../-tJ~-t)r/O . . Debts ot decedent must be reported on Schedule I, ITEM NUMBER DESCRIPTION AMOUNT A. ~ERAL EXPENSES: 1. Iff{ 77r~#t?'&- h/l/&"7</9L AGHp-~~ ~'7 P;y '?', ~ I .$t:-?iVr~">; ..z;vC. 47<J d#"H'~~~,/l/ I 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) 3(,., (YO ~,.~~ ~ slreel2ess ~ - // ;(A City slateMziP,(l"tl'// Relationship of Claimant to Decedent S jJtPL.J~ . 4. ProbaleFees -1&:7:;.&rtVltt~ -c:P,..r/S.r7<a,v/ ~PO/Tj f?'" 5. Accountant's Fees 6. Tax Return Pre parer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ /7-;/7&' (If more space is needed, insert additional sheets of the same size) ,,,,.,,,m.p.,,,. SCHEDULE I COMMONWEALTH OF PENNSyt VANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER P(h! ~, 5;4,,~7"""~7~ 7-/-cP~-Cf9'/CJ Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. j/j!,r"'IP',k( C",.v cI; /- &1' P Ct=-/VA/ ".A/H~ ~5) Y<6'Cf ( 3-,,// f!- /...;'r .3~ ) 7-, D./'s .c"",,~-7( tt1YV',k (.LAtu &.pfl(~ dh it/P~h~a-.7N4.L-=X';; ?; tJ?'-;.-- b /~7S ~'IL.I.;l.) Ctt,f(J,c-sf: /1--?- 7 /? ~.5- .3. ?'I'-/r~/ ($cP. b/l--k/74 N.,4,) ) 31 ~'i?e (/-6#r~tC9TJ (rz.C' hd/fN'cl'ftL 5(S;-M"c ~ {!lfll ML tJ,NE ( ~/~/'- ..,Z:;;i/k. ~V.,/.L.C-) J/~~'7?- ~1-1r~pJ bA-k-/ ~~#S- --- C'r -17 ?c? tf jJ C::k-~ r- ~7<V/Cc-'JI..hVC:- .3. irt~ ( LAvY 6'~u->" ~A ~;4.t&.:;?1I ~z;61? Ld) ~~t&--sf: ~c1 ~~~ t, V~--,<! IZ-C'N ct.) /fIe.: '7/7- '737-/f3'iJ'-;;.67--1'&' t 7-;73 ~) /tIC; 7/7~ '7~t?~/67-!;J--1'~?f-tft~r 33 ."c) /lie: 3/'1/ '1~~~-CJOt:'cP/ CIt!I,f/4-x>) ~r 1 -7#/~7/Y/!-L "f~'1I,e-N;I.IA-"" ~7I"1 ~ a.) ~!t'f/kt&~ ;O~~i.t M-M--SJArfiZ-~ . I'l"""r ~-;;(,..'q= a,tt~ VI "";9;6>- 7-/7CJ t:, / ~~ /'1''1'1 (I//'/fr-!-I':~~r) , fi.)~';'~-7< ft0.c--z (;~~)tbtf/}:-rp. (/i7;f~~ ~J-- ----- TOTAL (Also enter on line 10, Recapitulation) $ 7-'J(.f;I(]J/ (If rnore space 's needed, Insert addillonal sheels of the same size) REV-1513 EX+ 19-00. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER .- 2-/-t1. ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not ListTru""(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and trans1e(s under Sec. 9116 (a) (1.2)] 1. /Y ~&-,{-- /~/!-S ~h 4- J~* /=?3tf )).(S~(/3z/~o./lI- 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 ,. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ,. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (Ii more space is needed, insert additional sheets of the same size)