HomeMy WebLinkAbout05-31-06 (2)
~tV-158Q EX (6-C~)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
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~ 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 (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
FILE NUMBER
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COUNTY CODE YEAR
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NUMBER
SOCIAL SECURITY NUMBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED.. ALL CORRESPONDENCE AND CONFIDENTIAl.. TAX INFORMATION SHOULD BE DIRECTED TO:
NAME 'V E h :s1- COMPLETE MAILING ADDRESS
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FIRM NAME (lfApplicab ) I' U
TELEPHONE NUMBER/ (7- '-97- ~ ;;200 M ecla.......;<-.s ~ '-r.f''j ~D.i'b
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
4. Mortgages & Notes Receivable (Schedule D)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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)
9. Funeral Expenses & Administrative Costs (Schedule H)
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)
(1 )
(2)
(3)
(4)
(5)
--
qA/3 '01 00
---
-
(6)
~ 7 6 ~4 i 03
(7)
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(8)
Z '''OSJ.!. S-2
(9)
(10)
I 't?". 2 2
20025\ '/0
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)
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
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
x.O_ (15)
x .0 ""5 (16)
x .12 (17)
x .15 ( 18)
(19)
/'1"'-1032. G. 0
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I
(11 )
(12)
(13)
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19"1032., '0
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
(14)
I f'Lf 03 z . c~
g731, "f7
g73/....,7
> > BE SURE TO ANS~NER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
STREET ADDRESS g37 F. P,n JI"fZ- RcJ f}DOJ;-.. ... .3 0 '7
a,,~fr UA@~~>' ~
CITY tL{ edt:Lvl,';~s k Pit '7OS0
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ZIP 170SD
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
<2731,'''{7
---
312.77
-
3. Interest/Penalty if applicable
D. Interest
E. Penalty
3 tz ~77
Total Credits ( A + B + C ) (2)
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)
--
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
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A. Enter the interest on the tax due.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
g'4.f 1 )).97
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 use 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, 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? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 15'1
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.
SIGNATURE OF PERSO~ESPONSIBL FOR FILlN. G RETURN
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ADDRESS
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DATE
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DATE
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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 P.S. S9116 (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 for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)).
The statute QQes 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 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. 9911 6(a)( 1.2)}.
The tax rate imposed;!: the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 PS. 99116(a)(1 )].
Tre ta'"( r3te imposed on the net ulUt or transfers to or for the use of the decedent's siblings is 12% [72 P.S. s9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
inJividtJai W.:o has at least one parent in common with the decedent, whether by blood or adoption.
RE,V-1502 EX+ (6-9*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
4ntt- 13,
FILE NUMBER
2/- os-- O~j7
F~s+
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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
N{)~~
o
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
R~-1503 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
pn"~ E.. F~r.s+
FILE NUMBER
;21 o:r-O~S~
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
5
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
(9 /(,00 5't. cU es of {~€. Hers~~y
.i- oe-k CC>~ jAV\d OD ~ ko1.. Q'^-. S' +0 c k Cfl13W,co
'i. 12- oS"
'i'~ Cf-(5S
/-cw ~~ t.. 6~ ~
,----
.- SC( 102., SCL 31
sg. \.g _,'1. j r
...
TOTAL (Also enter on line 2, Recapitulation) $ q~ g~o .00
(If more space is needed. insert additional sheets of the same size)
REV-1504EX+(1-97) r
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
f1nn~
E_ ~~S+-
FILE NUMBER
:l1-oS-- o~S-2
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent. other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
1(t:J(r1~
o
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
. ~1~'j1~ '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Corporation
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
Product/Service
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? 0 Yes o No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? 0 Yes o No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? 0 Yes 0 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 0 No If yes. 0 Transfer 0 Sale Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a written shareholder's agreement in effect at the time of the decedent's death?
If yes. provide a copy of the agreement.
DYes 0 No
10. Was the decedent's stock sold?
DYes 0 No
If yes. provide a copy of the agreement of sale. etc.
11. Was the corporation dissolved or liquidated after the decedent's death? 0 Yes D 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? 0 Yes 0 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 stock.
B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 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 value/s. 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-1506 EX+ (9-00)
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Partnership
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
4. Decedent was a o General
N tf1.
Date Business Commenced
Business Reporting Year
State Zip Code
Product/Service
o Limited partner. If decedent was a limited partner, provide initial investment $
5.
PARTNER NAME PERCENT PERCENT BALANCE OF
OF INCOME OF OWNERSHIP CAPITAL ACCOUNT
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 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?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
1 D. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No
If yes, provide a copy of the agreement.
Date
11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 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? .................................... 0 Yes 0 No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
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 1 D65) 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/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
RIiV-1507 EX+ (1-97)
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
/Jnl1a.- E F~,sf-
FILE NUMBER
~J-OS-6&'S,p
All property jointly-owned. with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
f./~we
o
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-15t\8EX + (1-97)
'*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
A^hO- E - +urs+
FILE NUMBER
2, -oS- - DB.5~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
S'e.~
s~~~k F
......
-
.---
--
5'~t\.l \ <<'-~Ok~:t
C ( to .j... k -e..s t1 i v"'.....
of- tt..u"" ~., :r \.A..,re +-
To J .d v<>v-h C)t.-. A-r-:J'
'-' Ca.-~
sda
..i' ~ ("$ .
dO.
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1~ EX + (1-97)
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Anl'CL- f;.. -F(..(As-t-
FILE NUMBER
2,,/- oS- - tJ2S'9
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. 1)-odb..s f:
F '-'... .rl-
1."0
s;,lver 5rl"I.~ ~o-cJ
vvt ~ Pit l7~-o
son
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. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. ~. - .JO..()t( Uo..rt~ Na..1-~ o~a.( ~ fh<l k ~5"3'2.oS SOb .3-. I 4 24./.. 03
Ghecb "';\ 0. C c... 0 \.4.,.~"" +-
.. f q I ~Jgl..(
TOTAL (Also enter on line 6, Recapitulation) $ 2, 7(.;g4, 03
(If more space is needed, insert additional sheets of the same size)
REV-1510 p< + (1-97)
'*
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
A-;'\" 0- E- ~rsf-
FILE NUMBER
~l- OS- -O~Sg
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.
ITEM
NUMBER
1.
DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
%OF
DATE OF DEATH DECO'S
VALUE OF ASSET INTEREST
EXCLUSION TAXABLE VALUE
'"DO<<J la.ss E.
I-""rs -+ - Son
9L1CJlo. So
q.:.e~ (;)1 €>,50
2- Tt.J,cL 5""....... -t-"-- p~",+~.
~ I 1)~~
I ra..~S' ~~I 0 \#"-
TOTAL (Also enter on line 7, Recapitulation) $ 94olo..)V
(If more space is needed, insert additional sheets of the same size)
RE;J-1511 EX+ (12-99) t
.~bJ~~
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
p(1~O- E-
~
t-(A,~
FILE NUMBER
a-I- oS' - o'g S-2
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
FUNERAL EXPENSES:
DESCRIPTION
IJer~e..y ~~-h.-rt'
C'~d
~"dlS+
r (oW f'JrS
~ ~ ~ .... ~ It\.i eo...- 0.... i.J$
A~er t-~e-ra..l HCi.ke....
AMOUNT
~OC;OO
7.:r~ C)-t;,
7S1 ~o
"6,27-
I 10, 00
i ( t'1tQ, 00
1.
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
go, 00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ / 9 r ~, 2 2
(If more space is needed, insert additional sheets of the same size)
REV-~512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
An na- E. Fl.Awrs+-
FILE NUMBER
..2.,}-05- l)~52
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
2.
3.
I..{.
S.
,.
7,
$'
q.
Holy SFiro.+- HOS"fih.J
vJ ~~-.+- ~(o r-L. tZ. tv\. S-
LA) 'es+ S (c r-c... E }VIs
w es-+ $(0... <E tv{ S"
Ct?u...~ ~Y'" y l\..\. ~ G ..c; S LV e.s .f-
Ch e ;c:. e N \A...-r ~ -. ~-:i
Cko;c~ N w..rSl ~,j
=r ~l\(;L. .s-~. ~ .~ ~
The.. S+b\~ ~ Uepu+.
2. 12.00
5/, , I
j-71 7 (
S J-'. J ~
:3 '7~o.37
4272.7S-
I OS'" 4. ~-O
q 9yS;OO
.s-g] 0
1.
TOTAL (Also enter on line 10, Recapitulation) $ :}.... 0 0 2-~... 70
(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
,tk~~ ~. FUX'sf
FILE NUMBER
;, 1- 0.5'-0 gs~
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)] 50 % - 8~SO
1. 'j)o,,-~ !a-S"~ ~. ~s4- ~O,^
1)~h.t@o- 56% -- .d ;2--) l)
z. ~ ~ lA- ~~&-+h
3. M a.-~-e~ ~~\~ dr~ s o.~ $";J,SoO
C.r'e <1 fi) <(''I S' ~ \ .f.-l... ~..-a.J. so,- $' 3-~O 0
i../.
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 $
o
D
(If more space is needed, insert additional sheets of the same size)
REV~1514 EX+ (12-03)
. '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on REV-1500 Cover Sheet
ESTATE OF
4f\V\4- E.. F~s+
FILE NUMBER
~ (-OS -0 9S€
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 tor single life calculations can be obtained from the Department ot Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates ot death trom 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
LIFE ESTATE INTEREST CALCULATION
NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS
DATE OF DEATH LIFE ESTATE IS PAYABLE
o Life or o Term of Years -
o Life or o Term of Years -
o Life or o Term ot Years
-
o Life or o Term ot Years
-
o Life or o Term of Years
-
1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table .................................................
Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
ANNUITY INTEREST CALCULATION
NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS
DATE OF DEATH ANNUITY IS PAYABLE
o Life or o Term of Years
-
o Lite or o Term of Years
-
o Life or o Term of Years
-
o Life or o Term of Years
-
1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . .
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( )
3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................
5. Annuity Factor (see instructions)
Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions) ..................................................
7. Value of annuity - If using 31/2%, 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 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
Distributions From Pensions,
Annuities, Retirement or
Profit-Sharing Plans, IRAs,
Insurance Contracts, etc.
This information is being furnished to the
Internal Revenue Service
11 State/Payer's state number
PA/110S8682
BOX 10
STATE
TAX WITHHELD
COpy C
For Recipient's
Records
2005
Form Date
ORIGINAL STATEMENT 01/10/2006
DOUGLAS E FURST
260 SILVER SPRINGS ROAD
MECHANICSBURG
PRUDENTIAL INSURANCE CO OF AMERICA
PO SOx 7960
PHILADELPHIA. PA 19176-7960
PA 170!SO
~::~~ 10 #: 22 -1211670
172-36-1707
2b Taxable amount
not determined
D
Box 7
Distribution
code(s)
IRA!
SEPt
SIMPLE
BOX 4
FEDERAL
INCOME TAX
WITHHELD
BOX 5
EMPLOYEE
CONTRIBUTIONS
OR INS PREMIUMS
25000.00
D
4
9a Your percentage. of
total distribution
Total
distribution
BOX 1
GROSS
DISTRIBUTION
BOX 2a
TAXABLE
AMOUNT
47005.25 22005.25
* ACCOUNT/CONTRACT NUMBER: 97548479
PHONE: 1.888-778-2888 INSURED/ANNUITANT: ANNA E FURST
FORM 1099-R
OMB No. 1545-0119
BOX 12
STATE
DISTRIBUTION
22005.25
TOTALS
_ _ _ _ _ _ _ ~?QQ~._~~ _ _ _ _ _ _ _ _ _ _ ~~9Q~~~~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~~!QC) _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~2_09~_.~_
ORIGINAL STATEMENT
6 Net unrealize9 appreciation
in employer's securities
172-36-1707
1 Gross distribution
2a Taxable amount
$ 22005.25
Total
distribution
4 FederaJ Income tax
withheld
PAYER'S Name, Street Address, City, State, and ZIP code
PRUDENTIAL INSURANCE CO OF AMERICA
PO BOX 7960
PHILADELPHIA. PA 19176-7960
PAYER'S Federal 10 It
22-1211670
RECIPIENT'S Name and Address
DOUGLAS E FURST
260 SILVER SPRINGS ROAD
MECHANICSBURG
RECIPIENT'S 10 #
0039725
2005 FORM 1099-R
OMB No. 1545-0119
Distributions
From Pensions,
Annuities,
Retirement or
Profit-Sharing
Plans, IRAs,
Insurance
Contracts, etc.
This information is being
furnished to the Internal
Revenue Service
COpy B
Report this income
on your federal tax
return. If this form
9b Total employee contributions incom:h~:~ri:~:rJ
in box 4, attach this
copy to your return.
Name of locality 15 Local distribution
PA 17050
1 0 State tax
withheld
22005.25
Department of the Treasury - Intemal Revenue Service '
tate/Payer's
state number
PA/11058682
ORIGINAl STATEMENT
PAYER'S Name, Street Address, City, State, and ZIP code
PRUDENTIAL INSURANCE CO OF AMERICA
PO BOX 7960
PHILADELPHIA. PA 19176-7960
1 Gross distribution 2a Taxable amount
$ 47005.25 $ 22005.25
PAYER'S Federal 10 #I 2b Taxable amount T ota!
not determined distribution
22-1211670 3 Capital gain 4 Federal Income tax
(Ineludea in box 2a) withheld
5 Employee contributions 6 Net unrealized appreciation
or insurance premiums in employer's securities
RECIPIENTS 10#
172-36-1707
4
9b Total employee contributions
12 State 13 Local tax Name of locality 15
distribution withheld
$ 22005.25
RECIPIENT'S Name and Address
DOUGLAS E FURST
260 SILVER SPRINGS ROAD
MECHANICSBURG
PA 170!SO
1 0 State tax
withheld
11 State/Payer's
state number
PA/110!S8682
2005 FORM 1099-R
OMB No. 1545-0119
Distributions
From Pensions,
Annuities,
Retirement or
Profit-Sharing
Plans, IRAs,
Insurance
Contracts, etc.
This information is being
furnished to the Internal
Revenue Service
COpy 2
File this copy
with your State,
City, or Local
income tax return,
when required.
Local distribution
Department of the Treasury - Internal Revenue Service
IMPORTANT INFORMATION:
This Form 1099-R is used to report distributions from a Prudential/Pruco life insurance, endowment or annuity contract, or retirement or profit-sharing plan.
Transactions that can trigger taxable and reportable distributions include:
- Direct Rollover - Annuity Death Benefits
- Cash Surrenders - Outgoing Section 1035 Exchanges
- Contract Maturities - Assignments of annuities and certain life insurance
- Partial Withdrawals - Required reportable income as the result of the death
- Ownership Changes of the owner of an annuity contract - IRC Section 725
- Roth IRA Conversions
- Loan on Annuities and Some Life Contracts
- Incremental gain for annuity contracts owned
by non-natural persons - IRC Section 72u
- Return of Premium or Not-Taken Cancellations
- Lapsed or Exchanged life Contracts with an
Outstanding Loan
NOTE: Reinstatement of a lapsed contract with a loan does not cancel the reportable tax event.
Insurance contract distributions are generally taxable to the extent the distribution exceeds the owner's investment in the contract. Investment in the contract
generally is Premiums Paid minus Previous Non-taxable Distributions including dividends.
Please realize this Form 1099-R represents only a summary of 1099-R tax events from the account or contract number(s) listed. Therefore, you may receive other
tax statements from Prudential/Pruco if there were additional reportable events.
Dr1trlQnti~1 ic: ranlliron h\/ I~"'I tl"\ rn'.:lil t":1V ranf'\rtinf"'l fr\rn"\t"" 1n0l'1..C f,...".. ....f""\\I +...._ ""...... h" +h"",,, 11""11....... ........u:_ 1....._......_......-' 101....-. '.....11.........:__ __1___...1__ H___
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975~8~79
CC
. Prudential $ Financial
Prudential Annuity Service Center
P.O. Box 7960
Philadelphia, PA 19176
Variable Investment Plan
Annuity Transaction Confirmation
September 22, 2005
Page 1 of 1
>01045 3112329 001 092001
ANNA E. FURST
COUNTRY MEADOWS
4837 TRINDLE RD.
MECHANICSBURG, PA 17050
Investment Professional:
PRUDENTIAL - PFS
1848 CHARTER LANE
SUITE 214, FLOOR 2
LANCASTER, PA 17601-5896
A.r.nuity #: 97548479
Type: Non Qualified
Owner N9me: .d.f\Jf\I.A. E. FURST
Annuitant: ANNA E. FURST
For 24-hour access to your
portfolio performance, investment options, current account values and other information:
Sign on to our interactive Web site www.urudential.com
Or call our Automated Voice Response System at 1-888-778-2888.
For other inquiries on your Annuity Contract, contact your Investment Professional.
We recommend that you review this statement promptly. If you believe this statement does not properly reflect
the transactions, features or allocations you have selected, contact the Annuity Service Center immediately.
Total Investment Value $0.00
Investment Transaction Activity
Transaction
Date
Investments
t# of Units/
*lntenm Value
U nit Price /
*MVA
Value/
*Account Value
09/22/2005 Transaction Type: Death Benefit Surrender
The following amounts were withheld for taxes and! or deducted for applicable surrender charges from the total
amount shown below:
Federal Ta"'C: $0.00
Pre TEFRA Cost Basis: $0.00
State Tax: $0.00 Surrender Charge: $0.00
Post TEFRA Cost Basis: $50,000.00
1 Year Fixed
1 Year Fixed
1 Year Fixed
01/01/2006 3.450%
01/01/2006 4.150%
01/01/2006 4.000%
(41,519.38)
(36,371.68)
(16,119.43)
.$0.00
$0.00
.$0.00
($41,519.38)
(.$36,371.68)
($16,119.43)
($94,010.49)
Transaction Total:
Transactions in your variable annuity contract are priced at the end of the business day (generally 4 p.m. Eastern time) on the day the
transaction was processed.
Important Messages
Information regarding agent's compensation (remuneration) is available upon written request.
For ease of reference, we use a single set of defined terms in this statement. In certain cases, your contract may
use a different name for a contract feature than what is used in this statement.
Annuity is issuf'd by thE' Prudf'ntial Insurancf:' CompAny of Amf'rica.
Agent ID#ECG380 Office #SWIX
01045311232900104600305400001100001
~j [~~ ~j1 [~~,gl@
IW~~ti~I-~lIIJ
...>-
~..
~""~
I.;.~~'...,
~
The Hershey Company .~' '--
September 28, 2005
tOflf
1,00 q
II~-
'(J
Ms. Agnes Martin
Mellon Investor Services
Company Items Department
85 Challenger Road
Ridgefield Park, NJ 07660
Dear Agnes:
Enclosed are hvo (2) stock certificates totaling 800 shares of The Hershey Company
COIIlI!10n Stock registered in the name of Anna E. Furst (FURST ----ANNAEOOOO).
Mellon is also holding 800 shares in this account in book entry. Also enclosed is a death
certificate for Anna E. Furst and a copy of her Last Will and Testament. Therefore,
please reissue these shares as follows:
Julia Smith
3910 Long Grove Road
Brookfield, WI 53005
SS #: 169-44-6291 "'-0-
# Shares: 800 (In Book Entry and Dividend Reinvestment)
Douglass Furst
260 Silver Spring Road
Mechanicsburg, P A 17050
SS #: 172-36-1707
# Shares: 800 (In Book Entrv and Dividend Reinvestment)
If you have any questions, please call me at (717) 534-7530. Thank you for your
assistance.
Sincerely,
l;~<1{'~1~
Gay {iKaylor 0
Senior Stockholder Relations Representative
Enclosures
Cq.~E('Furst
100 Cr:lstal A Drive · PO Box 810 · Hershey, Pennsylvania 17033-0810 · (717) 534-4200
000000141
I I
I I
~ Prudential
."Financial
The Prudential Insurance Company of America
Prudential Annuity Services
P.O. Box 13686
Philadelphia. PA 19101
Check Statement
DOUGLAS E FURST
260 SILVER SPRINGS ROAD
MECHANICSBURG PA 17050
Date: SEPTEMBER 26 2005
Owner: ANNA E FURST
Annuitant: ANNA E FURST
Contract #: 97548479
Product: Variable Investment Plan
Market Type: Non Qual ified
Page 1 of
......-.......... .. ........ . ..... -, .............. ......................
.................,.......
.......i...iii..........t~IIII~.II:"'_IJII~lt_Ir.~!!~!!~!!!!~g....................................................................................................
Thank you for your patience while we completed your request for death benefits from the contract
listed above. The table below provides a breakdown of how we determined the net check amount.
Taxable amounts are reported to you and the Internal Revenue Service. The federal taxable amount
of your payment is $ 22005.25. The state taxable amount is $ 22005.25. We have presented this
information based on our knowledge of tax law. You may wish to consult your tax adviser if you have
any tax questions. Because each Situation is unique, neither the Company nor its representatives
can provide tax advice.
Financial Breakdown Information
GROSS FUND WITHDRAWL AMT
NET AMOUNT OF CHECK
47005.25
47005.25
(VP AS d055216)
PLEASE DETACH CHECK - KEEP STATEMENT FOR RECORDS
.. .,-.- ~._'-' --~._---_..._-----
"