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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
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DECEDENTS NAME (LAST FIRST AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
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I THIS RETURN MUST BE FILED IN DUPLiCATE WITH THE
I REGISTER OF WILLS
SOCiAL SECURITY NUMBER
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(IF APPLICABLE) SURVIVING SPOUSES NAME (LAST. FIRST. AND MIDDLE INiTIAL:
~ 1 anginal Return
D 4. Limited Estate
D 6 Decedent Died Testate copy
D 9 litigation Proceeds Received
D 2 Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12.82)
U 7. Decedent Maintained a Living Trust (Attach copy of TrJst)
D 10 Spousal Poverty Credit ;cate 01 death between 12-31.91 and 1-1.95)
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l~ 3. Remainder Return ,date of de ate, pnor to 12.13-82)
[J 5. Federal Estate Tax Return Required
8 Total Number of Safe Deposit Boxes
=:J 11. Election to tax under Sec. 9113(A) (Attacc See
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THIS SECTION MUST BE COMPLETE,D. Al..lCOR~SPONDENCeANDCONFIDE""".AL't~i"F()IlMA'fI()"'SfflJlILQ't=.QIRECTeO TO:
NAM L-' UO t' III ~. COMPLETE MAILING ADDRESS
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FIRM NAME ,If Applicable;
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Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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3 Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
(6)
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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)
(7)
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3~ I C1 ~-cr,'7 J
(8)
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J. 5 Ll ;). I. Co '7
(11)
(12)
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I~ 84 y; C(Y
9 Funeral Expenses & Administrative Costs (Schedule H)
(9)
(10)
10 Debts of Decedent, Mortgage Liabilities, & Liens (Schecule I)
11 Total Deductions (total lines 9 & 10)
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)
(13)
(14)
Li<6'-f'S-.'34
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 See 9116 (a)(1.2)
x 0 _ (15)
16. Amount of line 14 taxable at lineal rate
x.O _ (16)
17 Amount of line 14 taxable at sibling rate .y'-~ 4~, '6'-4 x12 (17) S~ 1.<3G:J
18 Amount of Line 14 taxable at collateral rate x .15 (181
19. Tax Due (19) Cl<3 I . 'S'G;
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER AlL QUeSTIONS ON REVERS'ESlQI;AND ~ECHJ!Cf( .MATH <t "'.
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Decedent's Complete Address:
I STREET ADDRESS
CITY
I STATE
ZIP
Tax Payments and Credits:
1. Tex Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits ( A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( 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)
B. Enter the total of line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
....0 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 reversionary interest; or............................. ..................... ............................
d. receive the promise for life of either payments, benefits or care? ........ .............................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................ ..................................................................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....
4. Did decedent own an Ir,dividual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .............. ........................... .......................................
Yes
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No
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Under penalties of perjury, I deciare 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
Declaralion of preparer other than the personal representative IS based on all Information of which preparer has any knowledge
XATURE OF PERSON RESPONSIBlE,FOR FILING RETURN
~I~"'A
ADDRESS
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
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 PS. 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 PS. S9116 (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
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 paren
or a stepparent of the child is 0% [72 P.S. s9116(a)(1.2)J.
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. S9116(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 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as a
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV.1508 EX . (1.97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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
Pi\IC. of\rJk ~H ECK' IrJCo
/4 CCT # 5 0 - () 437 - 3 G I L,
VALUE AT DATE
OF DEATH
304GB ~
TOTAL (Also enter on line 5, Recapitulation) $ ~n '4 L-. S< '"
(If more space is needed, insert additional sheets of the same size)
REV-I509 EX + (1-97)
SCHEDULE F)
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
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. C(;I~ :STANCE..'-r6 u t0S
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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. V ALIJE OF ASSET INTEREST DECEDENT'S INTEREST
2/ ,/ c ) I"D C: ;~ TI1 ,- \~/'I r-.l iL- i 5" L.t '5 C0 . --te' _5C~ '~~:
1. A. l-crC:K 1\ '\J- rc-; '2-
x: 1(.)'5 '.) i C bblJ
TOTAL (Also enter on line Ei, Recapitulation) $ ,1 ;)...'3 1-.0
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(If more space is needed, insert additional sheets of the same size)
REV~15,1 EX+ (12~99) .
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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 H cr TlclCL< Fv.v\. jCf~ L
\-~c'(V\ E. G~ )' 't' l.O
-S'H It-.::) fC~ f\/ '~: l'~ \-+--> ',~ '~.'.-(~.)..~_, (.'1-C_ e~:,?'\.,
( i-t-I..::;:-r\("'\ -<:~'TCf'...Jt~") I 00f., c'C
l\.it v.~ r)'~\(.';'f...,~1 {,':;" f'-\(',\.(,~::: (' ,. ,<. C . f) 1. I'SCU
15 ' ! ) ~ -',
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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 \ 50 cD
3. Family Exemption: (If decedent's address is not the same as claimant's. attach explanation)
Claimant
Street Address
City ___~ .________ '".u____________________ State ____ Zip
Relationship of Claimant to Decedent
4. Probate Fees I '-t C: GC
5. Accountant's Fees
S '5. 00
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, ')q J. I - ,
Recapitulation) $ \? '- I
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(If more space is needed, insert additional sheets of the same size)
REV.t~12 EX... {1-97}
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COMMONNEALTH OF PENNSYLVANIA
INHERlrANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
ITEM
NUMBER
Include unreimbursed medical expenses.
I
DESCRIPTION
AMOUNT
1.
Q ( C,-, 1.kY'/1Cr"\ t. rJ 0 rs! ru C -t- Re iM B i L ~I 0'1--J cnc
C.n. it" \(:: '2.
.~ <t G:") ~ 0 c;
II1ETice ,'y'E.~D - l\/CJ;\.) Tfc.{ja:.S,j'C:i<:-\(r~IC'O\l
c!.v.: ~ I c{i
'5 (, 2. S()
LtL..lf.C:;T'E..2: hMf't PHY'~ Il'\C'rd Ce,{, (:~.""tt:....--"...c.'
~"L*\,C . ")
(CI.C2..
wu~ 'f ~) ~"c~\r:;- E. VY) 5
<'-RW III
7J, . I Y.
i))" '\
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Ct'l..,t;F \12
11.7'7-
C~-.l'1lCA-L .(\~~ tV ~ n Grt.p 4C . 4/
C'lc:W ! \ '-t
TOTAL (Also enter on line '10, Recapitulation) $ .:;1, '5lt J. ( , (/l
(If more space is needed, Insert additional sheets of the same size)
REV-1513 EX+ (9-00) "
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
~~UMBER NAME AND ADDRESS OF PERSON(S) FECEIViNG PROPERTY
I TAXABLE D, IST,RIBUT ION,S, [include outright sP,ou, sal distributions, and transfers under
See, 9116 (a) (1.2)]
1. C
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RELATIONSHIP TO DECED~I
Do Not List Trustee(s) ,
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AMOUNT OR SHARE
OF ESTATE
'-1 "'~ 4 ';?, ~,;; Lf
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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 SECTlmJ 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-TAX,~BLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)