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RE1I-1500 EX (6-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
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FILE NUMBER
COUNTY COOE
YEAR
NUMBER
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
K G./r .J2., J./Z;", C. c.. Ice J ,f
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
().r - 1 J-...)/J() J l>-C -I ~ -I 'j'1'
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
1. Original Retum
D 4. Limited Estate
~Decedent Died Testate (Anach copy of W~I)
o 9. Litigation Proceeds Received
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NAME /l .
(.f- 13,
FIRM NAME (If Applicable)
SOCIAL SECURITY NUMBER
e { - :J 0 - ..s :1.. J- (
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2. Supplemental Retum
D 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (dale of death between 12-31.91 and 1-1-95)
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Retum Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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COMPLETE MAILING ADDRESS
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(5) 'f'~')....
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rC_2 OF-FiCIAf;~SE ONTYT'!
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule 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. JoinUy Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & 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, Mort9age Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
TELEPHONE NUMBER
") I) - -CYI-IY?6
14. Net Value Subject to Tax (Line 12 minus Line 13)
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(8)
'(1)..')..--
(9) '{ y 2. (P. -
(10) 9'. -
(11) tI'12..1-.-
(12) -e-
(13) ~
(14) .e-
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)
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
19. Tax Due
x.O_ (15)
x.O_ (16)
x .12 (17)
x .15 (18)
(19) g-
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
REV-15l18 EX + (1-&7)
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT'
ESTATE OF
C.. C./"r. Jy r k~/ry.e- ~ dJZy
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
FILE NUMBER
1.
C- tt.f "-
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c.. ~ ..e. ck ~ ....../'
S&IIQ rJl- ~f4....
tt. C c::. ",-.q.. -C-
n 4. "''<
.:t:J;- '1611} 9;J. 36
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TOT At (Also enter on line 5, Recapitulation) $ '-I 7 A .t.. .-
(If more space is needed, insert additional sheets of the same size)
.
REV-1511 EX+ (12-99) .
. *
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL'EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
c. c.1 &1. cI y r
FILE NUMBER
k t( (I re.'j ~ar
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
1.
DESCRIPTION
FUNERAL EXPENSES: " "
C. .9c:k ","\.. p"'-..6/' CI. ( fit>""" - - f,.)4(. ef.~..A- rl~ r lJ"'.I/ 4- (
C-',fI'.f1ic:.t... f'/IlSLHAtiPrlH.U' - Q)aL J,v.c.- F.lV' h<-~/.r-rJ>k--
AMOUNT
/e3'1-. -
.2 9P. -
.](,. -
:L.
;3 , f'..JJ- c: ..e-/7 '; () ~'\.
B. ADMINISTRATIVE COSTS:
1.
Personal Representative's Commissions
Name of Personal Representalive(s) c., ~. r.€. ~ fA-
Social Security Number(s)/EIN Number of Personal Representative(s) j Y ~ - j r - ~ ') &J C/
Street Address J f) ;2. C ~ ~ r 1': r1.~ /,,, .. ;.l yo .
rot>. -
City
Jl6 j1 .
State ft Zip /., /1 P
Year(s) Commission Paid:
::.204>6
2. Attorney Fees
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
;1..<19).. -
Claimant C. ~ yo S> / 't ...
Street Address /.L C., ( .P
City /n Il r'~.r ~
I'
J-J.~ fJ
~I r ., '" !' s I{ Jl.
State M Zip I" /) / ?
.
Relationship of Claimant to Decedent
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4.
Probate Fees
7 ,-. .-
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 'I r ,). 6> _ -
(If more space is needed, insert additional sheets of the same size)
REV.I512 EX. (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
C. ' C- I 4. ~ Y ( k t:lITI'.L ~ cJ.I1- ,
FILE NUMBER
Include un reimbursed medical expenses.
ITEM
NUMBER
1. V.Q"i~o"" Fil-""~(
DESCRIPTION
f41>I<A- Io'~ ~I
AMOUNT
.2. C.
;. .
&Itt 4- C-KS '; _ T~..c.... W\~... l - /'/,.- c.-t.-.rz.. c,kJ
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D t' ~1 ~ ,/
It)- ....
6 ~ ~ \
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TOTAL (Also enter on line 1 0, Recapitulation) $ 9 f&,. -
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
G-. 6 J."""A"'~ F~ 4 /.IL-
JO~ c..,^~11'~'^-~7J),", AI" ri~f' It?- /"1 II~
RELATIONSHIP TO DECEDENT
Do Not List Tru8tee(s)
AMOUNT OR SHARE
OF ESTATE
NUMBER
I
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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.
TOTAL OF PART II - ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ - J
(If more space is needed, insert additional sheets of the same size)