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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
OEPT. 280601
HARRISBURG, PA 17126-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DENTS NAME (LAST FIRSJ-fNO MIDDLE INITIAL)M
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DATE OF DEATH (MM.DO-YEARj DATE OF BIRTH (MM-OD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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o 1. Original Return
o 4. Umited Estate
~ 6. Decedent Died Testate (Attach copy 01 Will)
o 9. Litigatiol1 Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (dale of (1eath after 12-12.82)
o 7. Decedent Maintained a Living Trust (Attacn COllyolTrust)
D 10. Spousal Poverty Credit (dale of ~ealh betll/tl9l112.31.91 and 1-1-951
OFFICIAL USE ONLY
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FILE NUMBER
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COUNTY com: YEAR
1I101r-
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NUMBER
SOCIAL SECURITY NUMBER
IR'f - /6
7773
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WillS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of deall1 priOr to 12.13.82)
o 5. Federal Estate Tax Return Required
Q. 8. Tolal Number of Safe DepoSit Boxes
o 11. Election to tax under Sec. 9113(A) (AIt8thSchO)
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FIRM NAME (Ir Awbble)
TELEPHONE NUMBER
111-1'" ..q6Ytf
1. Real Estate (Schedule A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Joinl1y 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)
COMPLETE MAILING ADDRESS
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(1 ) 0
(2) d
(3) ()
(4) 0
(5) .:< J,
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(6) (J
(7) 0
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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)
13 Charitable and Governmental BequeslslSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(9)
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(10)
14. Net Value Subject to Tax (line 12 minus Line 13)
SEe INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amolint of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a){1.2)
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16. Amovnt of Une 14 taxable at Jineal rate
17. Amount of Line 14 taxable at Sibling rate
18. Amount of L,ne 14 taxable at collateral rate
19. Tax Due
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x.O_ (15)
)( .0 ';.,'i (16)
)( .12 (17) .
x .15 (18)
(19)
(8)
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(11) 5, 5o~. 70
(12) /51 '7 I $' 1/
(13) 0
(14) J5, 7/? q/
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707. 35
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CITY
Tax Payments and Credits:
1. Tax Due (Page 1 LIne 19)
2. Credits/Payments
A. Spousal Poverty Credtt
B. Prior Payments
C. Discount
(1)
Total Credits ( A + B + C ) (2)
3. InterestIPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( 0 + E ) (3)
4. If Une 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request 8 refund (4)
ZIP 1-10 II
707. 3S'
5. If Line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE.
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A. Enter the interest on the tax due.
(5)
(5A)
B. Enter tile total of Une 5 + SA. This is tile BAlANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
707. 35
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
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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
Co 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 deatl1? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneflciary designation? ........................................................................................................................ 0
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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 lI1at I have examined this retum. indudlng accompanying schedules and statements. and to tile best of my knowledge and belief. It is true. correct and complele.
Declaration of pl8!l8l'eI' other than 1118 personal represenlatlve ;s based on aU Information of which pr8parer has any knClYtledge.
SIGNATURE OJ:l;ERspN RESP~lBlE FOji,FILlNG RETURN
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ADDRESS if 0 I/J ~.1
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
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DATE /
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ADDRESS
DATE
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 sU1VMng spouse is 3%
[72 P.S. ~9116 (a) (1.1) (1)1.
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 survlvmg spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii
The statute does not exempt a transfer to a survMng spouse from tax, and the statutory requirements for disclosure of assets and flUng a tax retum are still applicable even
the surviving spouse Is the only beneflciary.
For dates of death on or aftel' July 1, 2000:
The tax rate imposed on the net value of transfers from 8 deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive pare
or a stepparent of the child is 0% [72 P.S. ~9116{a){1.2)I. ~\
The tax rate Imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiari~xcept as noted In 72 P.S. g9116{1.2) [72 P.S. 99116(a}(1)J.
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. i9116(a)(1.3)]. A sibling is defined. under Section 9102. as
individual who has at least one parent in common with the decedent, whether by blood or adoption.
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COMMOHWEALTH OF PENNSYLVANIA
INHERITANCe TAX RETURN
OECE ENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
'IJ ('("0/ t1/ ell rf'O / tt *5
FILE NUMBER
aOO!J--dOyr
Include ... proceeds of _ation and the date the proceeds were l8C8lved by the estatB. All property joIntIy-owned willi the right of IUrvlvorahip must be dItIcIoMd on Scfledule F.
ITEM VAlUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PI( c 8,,,)<. q~cr fI. IiJ..o 37D... 3 ~1:a.. I~ 2:l. I. III'
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3 i () 0 O. 4<1
TOT At (Also enter on line 5, Recapitulation) $ :l" ";1. /, 'I
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
ESTATE OF
ITEM
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A.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
{krrlJ /U 5
~ 0 () 5' - 0 10 If P
m.
Debts or decedent must be reported on Schedule I.
1.
OEsCRIPTION
FUNERAL EXPENSES: /YJ ilI..! e..Zz./ r" nerd
. fW'lan hat6ut. )dt, dJ~*lIlaJUllfI ~
rttllVd... L u ncltlvl
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3(){),L,4'I;t";,,. '
AMOUNT
3,3 () 1-. /0
l1/e
_ eder't!r
3 (JtJ _ 4(J
1. Personat ~ntatIve's Commissions
Name of Personal Representative(s)
Socia! Security Number(s)/EIN Number of Personal Representatlve(s)
Street Address
2.
5.
6.
7.
...
City
State _ Zip
Year(s} Commission Paid:
A1tomeyFftS ~mt.s 8tJfar - ~~nsu..lh:.;I-t.~1f-
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Flmilyaemptton:{Jf~. addr*.:oct tI'Ie'aamt~-clairMnl's. attach explanation)
Claimant' . ;,:~>"j ,,'
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ACcount8nrtFees Tit ~ 1 e fur"-- 2'" 5'
State _ Zip
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Tax Retum Preparer's Fees
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TOTAL (Also enter on line 9, Recapitulation) $ T'J ..
(If more space is neecsea,1nSert addItiOnal sheets of the same size)
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SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE liABILITIES & LIENS
Carro/tiS
FILE NUMBER
~o05 -010 'f?"
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RE OE
ESTATE Of
Include unreimbursedmedical expenses.
ITEM
NUMBER
1.
DESCRIPTION
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A.
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AMOUNT
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:l s: fo
5'"1; n.
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3(,. ,}1-
/1. "J../
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TOTAL (AlSO enter on line 10, Recapitulation)
(If more space is needed. insert additional sheets of the same size)
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$ II ~ ~O.
, REV-1513 EX+ (9-00)
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~TH OF fttNNS"tLVAMfA
INHEAITANCE TAX RETURN
REStOENT DECEDENT
ESTATE OF
-... ..
BENEFICIARIES .
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, !'<" ,.,:.~"1'J.t:~~~.~5under
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L. Ca.rro ius.
.fell
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re~ r re_er
,~>;.-~~1ltRouGH'161'AS~~~~~%f;
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';~j~_ SECT10N 9113 f:QRWHICH.AN ElECTION TO TAX IS NOT BEING MADE
EW\TI;~-;'
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. B.' CHAAITABlE AND GOVERNMENTAL DtSTRIBUTJON$
PART n _ 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)