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Rev-1500
COMMONWEALTH OF
PENNSYLVANIA
otPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
FILE NUMBER
INHERITANCE TAX RETURN
RESIDENT DECEDENT
1
County Code
05
Year
0495
Number
SOCIAL SECURITY NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Califano Daniel
DATE OF DEATH (MM-DD-YEAR)
197 -70-9861
THIS RETURN MUST BE FILED IN DUPLICATE WITH
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
x 1. Original Return
4. Limited Estate
2. Supplemental Return
4a. Future Interest Comprise (date of death after 12-12-82)
3. Remainder Return (date of death prior to 12.
5. Federal Estate Tax Return Required
6. Decedent Died Testate (Attach copy of Will)
8. Total Number of Safe Deposit Boxes
7. Decedent Maintained a Living Trust (Attach a copy of Trust) D
10. Spousal Poverty Greait (date of death between 12-31-91 and 1-1-95) 11. Election to tax under Sec. 9113(A)
x 9. Litigation Proceeds Received
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THIS SECTION MUST BE COMPLETED.
NAME
Sam - r 0
FIRM NAME (If Applicable)
ALL CORRESFONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
COMPLETE MAILING ADDRESS
429 4th Avenue
2100 Law & Finance Building
Pittsburgh, PA 15219
TELEPHONE NUMBER
1-
Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
(6)
$0.00
OFFICIAL USE ONLY
$0.00
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$0.00 , I 1 =-I~ 0
$306,401.46 _c) 2;: F;
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
L:=J Separate Billing Requested
7. Inter-Vivos Transfers & Misc. Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(7)
(8)
$9,705.00
$38,144.03
9. Funeral Expenses & Administrative Costs (Schedule H)
(9)
10. Debts of Decedent, Mortgage Liabilities & Liens (Schedule I)
(10)
11 Total Deductions (total Lines 9 & 10)
(11)
(12)
(13)
12. Net Value of Estate (Line 8 minus Line 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 Tax (Line 12 minus Line 13)
(14)
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 Sec. 9116 (a)(1.2)
(15)
(16)
$258,552.43 x
.00
16. Amount of line 14 taxable at lineal rate
x
17. Amount of line 14 taxable at sibling rate
x
12
(17)
(18)
(19)
18. Amount of line 14 taxable at collateral rate
x
.15
19. Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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$0.00
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$0.00
$306,401.46
$47849.03
$258,552.43
$000
$258,552.43
$0.00
$0.00
$0.00
$000
$0.00
Decedent's Complete Address:
STREET ADDRESS 17 Kingwood Drive
,
CITY I STATE IZIP
Mechanicsburg Pa 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
$0.00
Total Credits (A + B + C) (2)
$000
3. Interest/Penalty if applicable
D. Interest
E. Penalty
4.
Total Interest/Penalty (D + E) (3)
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)
If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
$0.00
5.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
A. Enter the interest on the tax due.
$0.00
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:
a. retain the use or income of the property transferred;
b. retain the right to designate who shall use the property transferred or its income;
c. retain a revisionary interest; or
d. receive the promise for life of either payments, benefits or care?
If death occurred after December 12, 1982, did decedent transfer property within on year of death
without receiving adequate consideration?
Did decedent own an "in trust for" or payable upon death bank account or security at his or her
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
Yes
No
2.
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3.
4.
contains a beneficiary designation? c=J ~
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 b ad on all the formation of which preparer has any knowledge.
DATE
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DATE
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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 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 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 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. 99116(a) (1.2)].
The tax rate imposed on 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)]
The tax rate imposed on the net value of transfers 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 individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-150a EX + (1-97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
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
$651.30
PNC
Checking Account
2.
PNC
Savings Account
$50.16
3.
Guitars, Speakers, Mixers
$3,500.00
4. Miscellaneous Clothing $800.00
5, Snowboard, Boots, Rollerblades $200.00
6. Computer and Printer $750.00
7. Security DepositlFairmont Apartments $450.00
8. GEICO Insurance $200,000.00
Settlement Proceeds
9. Nationwide Insurance $100,000.00
Settlement Proceeds
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$306,401.46
REV-1511 EX + (1-97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Myers Funeral Home $6,565.00
2. Cemetery Easement $650.00
3. Internment Fee $750.00
4. Gingrich Memorial Bronze Marker $1,725.00
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
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
Inventory $15.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
8.
9.
10.
TOTAL (Also enter on line 9, Recapitulation) $9,705.00
(If more space is needed, insert additional sheets of the same size)
REV.1512 EX. (1.97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
1 . AES Student Loan
DESCRIPTION
AMOUNT
$10,972.00
2.
Sinai Hospital, Baltimore Maryland
$25,009.03
3.
Sinai Intensive Care Unit
Physicians Hospital
$860.00
4.
American Radiology Associates
$1,303.00
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$38,14403
REV-1513 EX + (9-00))
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BENEFICIARIES
ESTATE OF
FILE NUMBER
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)]
1. Pete Califano & Margaret Califano Parents 100 %
17 Kingswood Drive of Estate
Mechanicsburg, PA 17055
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 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $0.00
(If more space is needed, insert additional sheets of the same size)