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Home My WebLink About08-14-06 ..' ,.,. ~ 15056051047 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes . PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW c::> 1. Original Return - 2. Supplemental Return c::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c::> c::> 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death c::> 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o 8. Total Number of Safe Deposit Boxes 4. Limited Estate c::> c::> c::> Firm Name (If Applicable) Correspondent's e-mail address: be a mer Cs i)(. ne.t 'es of perjury, I declare th t have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, ion of preparer other than the ersonal representative is based on all information of which preparer has any knowledge. /7()SV DATE f'J ~ ~t, z 1lr h1&"(lHAAI/~S8HRt;~ PA /7I)SS-973'r PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J V' .-J REV-1500 EX Decedent's Name: RECAPITULATION 15056052048 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. . Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Scbedule F) c:::> Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::> Separate Billing Requested. . . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 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. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J). . . . . . . . . . . . . . . . . . . .. . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00- 16. Amount of Line 14 taxable at lineal rate X.O ~ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 1.9. ~ , Decedent's Social Security Number 15. 16. 17. 18. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052048 Side 2 c::> 15056052048 ---I ~EV-1 !)OO EX Page 3 Decedent's Complete Address: DECEDENT'S NAME File Number ;2..1- oS- - 6 'If) EAUlES7IAlG" A. LA-Jll:72. 'Ttt€ -,--_.~--~------~------~----_.__._-~--~---- f------~~ STREET ADDRESS {1;1. L~C<<.sT WA-Y ---------~---------~_._. ._~~-------~--~-------------------~--- ---~----~-- C/htU./s ~ E ---l---------~-------~..--------~------~------ - -- I STATE,iJA : ZIP /7c;/3 --- CITY (3) 0 (4) () 'iT' (5) I SO /. (p 3 (5A) 0 (5B) fC, $/. 63 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount o ------~--O-------- ---------0------------- Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty _________R_____ _______t:2_________ .~.__ 4. TotallnteresUPenalty ( D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Une S + SA. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (1 ) ,",Sf. b3 f) PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No 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 [2g" 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? .............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...... ....... ................................. ................................................ ................... ....... 0 Q9 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent (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 zero (0) percent [72 P.S. s9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory n - "--I--..ro,..,f ~~"ets and filing a tax retum 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 deat! adoptive parent, or a stepparent of the child is zero (0) percent [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 four and 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P. Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. '9 (t) /Jot l J J! (j f)~ ~ -/J/ItPO in ler Cfh- n , REV-15l'9 EX: (1:97) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNS't LV ANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF L,4v€l2rtl~ ~€Sr/Alc ~ FILE NUMBER Z/-tJS'-6f!D 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 RELATIONSHIP TO DECEDENT ADDRESS A. 'OA-II' D .:r: LlrtlEtl-TU.E B. c. b3 ~Jt.YLIN" 1>1l MEeHA-NI(~.S"Bu~, f'H /70SD SDIfl 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 DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 7/13/96 100 ~h. ~M. ~tI<. of T u. e SOf'l e\ t.eh-t'c. A lAIer CD~~ CUSIP ND. 'tQggl3 ., 0 If (/lGW WW\ 11.6 l(NISOU.rl (!E) ~c.es : ..r""M. 10lUOS h' .. ., . '30.02- '0 ~,.eo 'J lI..ne ,-a I 200S' hi "~.ot{ 10 -.;14i. 70 , 1 soZ , GUle.." ~ 9.19 )( 100 - ~, 'i "" IJ{) I, '/91. SV ,. A. 1/1' /'0 7, 000 sl.. C,4)1h. sH<. of E POL.II\J, I AJ e. CUSIP NO. 2t:t,/';7' II) D P~;c.e': :ru.r1t. 10, 2OOS' h; . sS'" 10 . S'I 1"LlN. 1'3. '2ooS hi'. .stf I". set , Soh, .,. t1JIt,. & . sf X ~ 000 = .3,7ItJ.OD J I 19(). ()f) TOTAL (Also enter on line 6, Recapitulation) $ 3, 3Blfl/ ~o (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 FILE NUMBER :2/... f)$""- 6~O '-A-VEI2.7ttGj C7(A/€.sT/NE A. Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Cost J- f;1,'''g S'^flp\~ td..o.r" w;if. R~s1ir t>!- /II;[/S " IS. ao TOTAL (Also enter on line 9, Recapitulation) $ IS: t) () (If more space is needed, insert additional sheets of the same size)