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Home My WebLink About10-03-06 .-J 15056051047 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes PO BOX 280601 Harrisbu ,PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number 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 ... 1. Original Return c;::) 2. Supplemental Return c;::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum 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 Da ime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received -'L 8. Total Number of Safe Deposit Boxes 4. Limited Estate c;::) c;::) c;::) ;po :x: 5 o w ',- Correspondent's e-mail address: Under penalties of pe~ury, I declare that I have examined this retum, 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 PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 .-J ~~ ~ --I 15056052048 REV-1500 EX Decedent's Name: RECAPITULATION 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 (Schedule 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/Sec 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 COMPUT~fION . SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers undet Sec. 9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.O li 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM~T ~1\ ~~\o ~\o j\\}- \ tf ~ if. ~ (Y .4) ..e";)Y sb ?T ~'e cY \0 Side 2 L 15056052048 Decedent's Social Security Number c:::> 15056052048 --I REV-1~OO EX Page 3 Decedent's Complete Address: DECEDENT'S NAME 13 If ~ ~.+ e If- PI I DtA...lCZ., STREET ADDRESS ~ File Number 'f CITY fr/~ 111J/(!shu.V' STAp 11- ZIP 176.5 CJ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) I 7 ,j ~ .=1. I () l' 5 ~.'- Total Credits ( A + B + C ) (2) RS-::I./c. 3. Interest/Penalty if applicable D. Interest E. Penalty ~~---~------- Total Interest/Penalty ( D + E ) (3) 4. 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SA) (58) / ~ Dl. 0 9, ? 1" Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS (~ 1. Did ~ent make a transfer and: Yes No a. retain ~e use or income of the property transferred;.......................................................................................... D ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~ c. retain a reversionary interest; or.......................................................................................................................... D c:rl d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D ~ 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? ........................................................................................................................ ~ D 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. ~9116 (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. ~9116 (a) (1.1) (ii)]. The statute does not exemot 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 adop!ive parent, or a stepparent of the child is zeroJO) percent [72 P.S. ~9116(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 one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(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.S. ~9116(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. "!",":"",.""" '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ll ,~ 1}ilfh II I!. 1'1 m , b l..t ~, SCHEDULE B STOCKS & BONDS FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 'PLLh J J c.. S +0 V' A--1--L- I "O().sL . ~. ~UJ "l ~ t:' D f}-", Qt ::J:jJc. //31/.229 SL. '3 c. () JfE..~ c:L .s +-e p.,s :::]:J..rl J ,e '" 7 Y F bl K' J 7 ;J.. 71 SI... , l/ tr} -l-r ~, 1/ J.. Y v~ r; J 0 loll-I 4/ J () C-II'" I JtJr~ IIJ~ .u... 5 c () '" ~ AJ -I S of f!.- -e t!J /C h. 'y ::t::.UC"'f<. ItJ 0.411 ['3', 173 ?( VALUE AT DATE OF DEATH etd.- 7 0". d " ea. I 4 oS 9. , / I ~ 1...//1/, 3' ~" '3 I'. ;LtJ I :.3 J/ A.. 5. O~- TOTAL (Also enter on line 2, Recapitulation) $ C; d.- .1/ '5. ~ :a.. (If more space is needed. insert additional sheets of the same size) ~_~'l"'. 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 reoeived 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 1. (!. ~ S .... 3lfJ!~. J~ ~ Fu. rt N I +u. ~-e.. -I fI (J u..~ "'e.. t.u 4 ~ tQ. I ~ ~ ~.O 1 3 t JJ- t2.. ? 3'7 S. tJ d Jj C*SJ.I Re..~AJD ~ +QLl'lfkON~ elf-v r^,~. R-e.~ :]:.N!3 j'd-~' 'I K ,e..f'€.-';/~ e~w-Q. III ~ ./ 5 Cj) me,e~, " J... Y A)e-L . ~ <' ) t:){)~ . 01 TOTAL (Also enter on line 5, Recapitulation) $ .239' <f.R' if (If more space is needed, insert additional sheets of the same size) ~~:m.".. .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER 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. DESCRIPTION OF PROPERTY %OF ITEM INClUDE THE NAME OF THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE . VALUE OF ASSET INTEREST {IF APPliCABLE \ NUMBER 1. e:( S~ S'9~ n IbO~ ~S3, f'95.? -::r:-~A TOTAL (Also enter on line 7, Recapitulation) $ ASJ ? tf'J"'. f{t; c (If more space is needed, insert additional sheets of the same size) REV-15011,EX+ (12-99) . .', '* 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. 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 500 '" 6. Tax Return Preparer's Fees St)().1)1 7. TOTAL (Also enter on line 9, Recapitulation) $ It'()d. tiP (If more space is needed, insert additional sheets of the same size) . . REV-' S.. EX+ 19-00* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT leMIDULI J BENEFICIARIES ESTATE OF <J3 All. b,.1tA FILE NUMBER y" J Ott.-., RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. l<e.v,.J ~ n1 ID lL.~J SOli , J -:J. J-<, N, ~ h1 ", cA- ~ "i-Il, S r6lt.\t-~ Pit- ,,116 .-1 /.{ e'R I II '" b r "e.. I y 1) ~I.{ 8' k -I-'l.l 5 S ~ DG.R= Lvoo I> D,. m <!Lkl'J N ,~ S Y.Y ~V', (),.. J 7055 AMOUNT OR SHARE OF ESTATE 3~.~ 3'3~ .3 'P'H~J D P'llbltvl ..so ~ ~ J' n V/S.J-.O L./<. Rt1l- /rt ~" J.Jle S b u.-Jrf Oil- 1 71) ~ '33Y3 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 $ (If more space is needed, insert additional sheets of the same size)