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Home My WebLink About11-14-06 .-J 15056051047 REV-1500 EX (06-05) PA Department of Revenue *' Bureau of Individual Taxes . PO BOX 280601 Harrisbur , PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Securi 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 MI o Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL.lN APPROPRIATE OVALS BELOW :Ci:) 1. Original Return -c::>> 2. Supplemental Return -C) c::::> 4. Limited Estate 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) t:=) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) t:=) 10. Spousal Poverty Credit (date of death ~ 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 8. Total Number of Safe Deposit Boxes C) "'" Correspondent's e-mail address: 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 based on all information of which preparer has any knowledge. SIGNATURE OF SON R FILING RETURN DATE Jj7 ,l 0 I DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 -I J --.J REV-1500 EX Decedent's Name: 15056052048 RECAPITULATION 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J() (!](./l. . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . .J./. ~ .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (~~. . .. 3. . .A,/~A 0 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . ~ .-:-':"':\ . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (SChedu~~.. 5. 6. Jointly Owned Property (Schedule F) c::;) Separate 7. Inter-Vivos Transfers & Miscellaneous Non-Probate P (Schedule G) c::;) Separate Bi ling Reques 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Lie~ule 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 w ich 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 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. . , Decedent's Social Security Number 6. 7. 15. 16. 17. 18. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT tof\P1?......Jh ......tt.... \... l\t"r 't' -L 15056052048 Side 2 c::> 15056052048 --.J . . REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME File Number I ~- STREET ADDRESS 1----- I STATE I ZIP -- CITY Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount AJ (1 ) Total Credits ( A + B + C ) (2) 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) B. Enter the total of Line S + SA. This is the BALANCE DUE. (5A) (58) A. Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT ~ m~1r~L .1/' II.En~IJ:lm]1i.r~"I~n III 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 ""EI b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 i;] c. retain a reversionary interest; or.......................................................................................................................... 0 'EJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 "'!;J 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 '-Cl 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 'L: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. 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 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 one-half (4.5) percent, except as noted in 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.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. RE}7-1502 EX.... (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of s,urvivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Aj TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) . RfV.I5113 EX + (1-97) '* COMMONWEALTH OF PENNSYLVANIA INHERIT ANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. N VALUE AT DATE OF DEATH DESCRIPTION TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV~l504 EX~ (1~9. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER NUMBER 1. DESCRIPTION AJ TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH . REV-1505 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FilE NUMBER 1 . Name of Corporation Address State_ Zip Code State on Incorporation Date of Incorporation Total Number of Shareholders City 2. Federal Employer I.D. Number 3. Type of Business Business Reporting Year Common Product/Service 4. Preferred $ $ 5. Was the decedent employed by the Corporation? If yes, Position Annual Salary $ . . . . .. 0 Yes 0 No lime Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? o Yes 0 No If yes, 0 Transfer 0 Sale Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....0 Yes 0 No If yes, provide a copy of the agreement. Number of Shares Consideration $ Date 10. Was the decedent's stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. Ust those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-l506 EX+ (0<>0. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership Address Date Business Commenced Business Reporting Year City State Zip Code 2. Federal Employer 1.0. Number 3. Type of Business 4. Decedent was a 0 General A. B. c. 5. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement. Date 11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1S07 EX+'(1-97) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV.l508 ~ + (l.sn . 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-l509 EX. (1.9n . 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 decedenfs date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS A. B. AJ c. JOINTLY -OWNED PROPERTY: LETTER ITEM FOR JOINT NUMBER TENANT DATE MADE JOINT DATE OF DEATH VALUE OF ASSET DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for joinUy-lle1d real estate. 1. A. TOTALJAlso enter on line 6. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) %OF DECO'S INTEREST RELATIONSHIP TO DECEDENT DATE OF DEATH VALUE OF DECEDENT'S INTEREST REV-1510 EX + (1-97) ESTATE OF . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ITEM NUMBER 1. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT 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 INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAl ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) EXCLUSION TAXABLE VALUE . REIJ1.1511 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 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-'S12 EX+ (1~-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-"'3 EX; (9-00* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER NUMBER I RELATIONSHIP TO DECEDENT NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] AMOUNT OR SHARE OF ESTATE 1. 64 M H 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION HICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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) REV-1514 EX+ (12-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV.1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Actuarial factor per appropriate table ................................................. Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) .. .$ o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) .......................... Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 0 31/2% 06% 0 10% 0 Variable Rate % 6. Adjustment Factor (see instructions) .................................................. 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-I644 EX+ (3-84) C}"'~~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE ilL" REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. Estate of (Last Name) (First Name) (Middle Initial) II. This schedule is oppropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) B. Name(s) of Life T enant(s) or Annuitant(s) (Date) C. Assets: Complete Schedul 1. Real Estate 2. Stocks and Bonds 3. Closely Held Stock/Partnership 4. Mortgages and Notes 5. Cash/Misc. Personal Property 6. Total from Schedule l- 1 D. Credits: Complete Schedule l-2 1. Unpaid liabilities 2. Unpaid Bequests 3. Value of Unincludable Assets 4. Total from Schedule l-2 Age on date of election Term of years incame or annuity is payable $ $ $ $ s s s E. Total value of trust assets (Line C-6 minus Line 0-4) F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) Also enter on Line 7, Reca itulation) $ S s III. Invasion of Corpus: A. Invasion of corpus (Month, Day, Year) B. Name(s) of life T enant(s) Date of Birth or Annuitant(s) Age on date corpus consumed Term of years income or annuity is payable C. Corpus consumed D. Remainder factor (see Table I or Table II in Instruction Booklet) E. Taxable value of corpus consumed (line C x line D) (Also enter on line 7, Recapitulation) s S $ ,;v.,.... EX. 17. COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-l REMAINDER PREPAYMENT ELECTION -ASSETS- FILE NUMBER I. Estate of (Last Name) (First Name) II. Item No. Description A. Real Estate (please describe) Total e of r (include on Se B. Stocks and Bonds (please list) n Schedule L) Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule l) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership $ (include on Sedion II, Line C-3 on Schedule l) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule l) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Sedion II, Line C-5 on Schedule l) III. TOTAL (Also enter on Section II, Line C-6 on Schedule l) (If more space is needed, attach additional 8Y2 x 11 sheets.) (Middle Initial) Value $ $ RE'-1647 EX. (9-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. o Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. to exercise a right of withdrawal within document in which the surviving spouse 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or inten 9 months of the decedent's death, check the appropriate block and attach a copy of th exercises such withdrawal right. o Unlimited right of withdrawal Explanation of Compromise Offer: o Limited right of withdrawal III. ~ bJ~ N. Summary of Compromise Offer: 1. Amount of Future Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One 0 6%, 0 3%, 0 0% . . . . . . . . . . . . . . . . . . . . . .$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One 0 6%, 0 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) RE,-,"1648 EX (11-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31194) ESTATE OF I FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE 1. Taxable Assets total from line 8 (cover sheet) ............................................ 1. 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6c. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6. SUBTOTAL (Lines 6a, b, c, d) .. . 6b. 6. 7. Total Gross Assets (Add lines 1 t 7. 8. Total Actual Liabilities ......................... ............ ...... 9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . . . . . . . . If line 9 is greater than $200 000 STOP The estate is not eligible to claim 8. 9. PART II - CALCULATION OF JOINT EXEMPTION INCOME (Attach copies of Federal Individual Income Tax Return for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse .............. . 1a. 2a. 3a. b. Decedent .................. .. 1b. 2b. 3b. c. Joint ................. . 1c. 2c. 3c. d. Tax Exempt Income . . 1d. 2d. 3d. e Other Income not listed above ....... . 1e. 2e. 3e. f. Total ................... . 1f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (11) + (2f) + (3f) (+ 3) 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... 1. 2. Multiply by credit percentage (see instructions) ........................................... 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. ............................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit . Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . .. 5. REV- 1649 EX. (1-9n . '* SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SPOUSAL DISTRIBUTIONS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION VALUE Part A Total $ PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made. DESCRIPTION VALUE Part B Total $ (If more space is needed, insert additional sheets of the same size) Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor 501 North Baltimore Avenue Mount Holly Springs, Pennsylvania 17065 STATEMENT OF FUNERAL GOODS AND SERVICES SELECfED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reason in writing below. If You selected a funeral that may require embalming, such as a funeral viewing, you may have to pay for embalming. You do not have to pay for embalm- ing you did not approve if you ~ ammgements spch as . tion or immediate qurial. If we charged for embalming, we witt exptain why betow. For the Serric:e of lei. c- 6 eA. f Date of Death Qargeto: L~.c. ~:"~ "0 C.l.^,~S ~c.l . 4sp~:s. ~. /7'!Oft Name Address City State A. alARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Services of Fooeral Director/Staff . . . . . . $ Embalming ..................... $ (}[her preparation of body Other clothing Cremation urn .. . . .. . .. . . . . . . . . . . S (Description) OTHER $ $ TOTAL MERCHANDISE sm.ECl'ED . . . . . . . . . . . . . . . ..B $ C. SPECIAL CBAltGF.S: Forwarding of remains to . . ... ........ ............. .... $ SUB- TOTAL OF PIlOFESSIONAL SElMCES . . . . . . . . ..AI $ 2. FACIUTIES AND SERVICES Use of facilities and services for viewiflg (Visilation/Wakt:) ......... $ Use of facilities and services for funeral ceremony ............ $ Use of facilities and services for Memorial Service ............... $ Use of equipment and services for graveside service . . . . . . . . . . . . . $ Other use of facilities $ (funeral Home) Receiving of remains from $ (Funer.d Home) ImmediateBurial.................$ Direct Cremation .~J............ $ _ .v1#1 .<:r""llf:orj . $'35~5 3'?&~'t SlJB. TOTAL OF SPECIAL CllAltGES ................C $ D.~V~~.................$ 2~ CcmcteryEquipment .............. $ =~ ~~!:~..i~~j~'(: IIJ~ .~ ,. fl. 80 Newspaper Notices-Out-of-town ...... $ Telephone & Telegrams ............ $ Airfare ........................ $ Clergy/Mass Offering .............. $ I<<J<D~ Pallbearers ......:.............. $ ~ Certified Copies of the Death ........ $ l_-b.i.' Certificate ...................... $ . Police Escort .................... $ Flowers . . . . . . . . . . . . . . . . . . . . . . . . $ /0#:> v.tultServiceCharge............... $ <h"rref'S~ : ~.lY) $ $ $ SUB-TOTALOF ADVANCFS .......................0 $ 3~.., . . . . ... . . . . . . . .. . . . . . . . . . . . . . . $ SUB-TOTAL OF FA<JLITIES/EQUIPM . . . . . . . . . . .A2 $ 3. AUIUM011VE EQUIPMENT 'khicle to transfer remains to Funeral Home Lcx:al ......................... $ Hearse (Casket Coach) Lcx;al .......................... $ Limousine Local ......................... $ Family car Local ......................... $ Rower car or f10raI disposition Local ......................... $ Lead car/detgy car Local ......................... $ Car for pallbearers Local ......................... $ Out of town tmnsportation .... . . . . . . $ $ SUB-TOTAL OF AUTOM011VE EQUIPMENT . . . . . . . ..A3 $ TOTAL OF PROFESSIONAL SERVICES, FACIUI'WS AND AuroMO'llVE EQUIPMENT ...................................A $ B.. aL\IlGE FOIl MEROIANDISE SEI.ECTED:' Casket. . . . . . . . . . . . . . . . . . . . . . . . . $ (Description) We charge you for our services in ohtaining: (specify casb advances that are markJed..up) SUMMARY OF CIWlGES A. Professional Services, Facilities and Equipment, and Automotive Equi~ ........ ............. $ B.~ .... ............. ... $~ C. Special Charges .................. $ D. Cash Advances .................. $ "2:J 'I TOTAL OF AU. SECI10NS . .. .. . .. . .. . .. .. .. .. ... $ oJ' I PAID AT TIME OF OR PRIOR TO ..:::r;J~~ec 3pfJ 0 ~~ ................... ....... .... $ BALANCE DUE .. .. . .. .. .. .. .. .. . .. .. .. .. .. .... $ rt:t I ? REASON FOR -" 2{ eJ Other Receptacle .... .. .. .. . . .. . .. $ (Description) Outer burial cont2iner ............. $ (Description) Acknowledgement cards . . . . . . . . . . . . $ Register book(s) . . . . . .. . . . . . . . . . . . $ Metnoryfolders .................. $ Prayer cards .................... $ Temporary grave marker . . . . . . . . . . . . $ Burial clothing ................... $ I agree that- I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge receipt of a copy of this Statemenl of Funeral Goods and;!!SeIected. I represent th& I have sufficient funds available for payment of the cash price for the goods and services selected. I also agree to ~e payment of $ ~ within~ ~ D days. I agree to be jointly and severally liable with ~ eJse who signs below. A late charge of .' ':. per month to iL I'; per year will be applied to the unpaid balance beginning -A1 days from the date of this agreement I will also pay to the F~ Director aD reasOnable costs paid by the Funeral Director to collect amounts I owe under this agreement. Those costs~y include.. !!!!OfJ1eYS' ~ court costs and other C08tS. Any additionaI services or merchandise ordered or requested aft er the date of this agreement will be """"'=' "':' of. _ _ -=- /~.J wJII be .- 00 1be IlnoI bUt ."..- J (Sell) X, . -----L2 - ""7 ~ U# ('" ( ) ~~ lS<>I) <...........1 t........t ~ _I o I'ennsyIYmIa I'uneraI 0inn0Is AssociaIIoo \IVHfTE FUner.tI DiRctlll' YEIl.OW Funeml DiI'eclor PINK Odcmcr form - 600 Revised 1/04