HomeMy WebLinkAbout11-17-06
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15056041046
REV-1500 EX (05-04)
PA Department of Revenue
Bureau of Individual Taxes
Dept. 280601
Harrisburg, 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
~\
6(j)
D
\5
Date of Birth
1- '5 J.. t/ t./ {g 9 0
19:J.DO
I /
I 9 ~ 5"
Decedent's Last Name
Suffix
Decedent's First Name
MI
C~"K'
CLAi/(E
s:
(If Applicable) Enter Surviving Spouse's Information Below
Last Name Suffix
Spouse's First Name
MI
Spouse's Social
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 Return Required
c::> 4. Limited Estate c::>
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
<:::)
c::> 6. Decedent Died Testate c::>
(Attach Copy of Will)
c::> 9. Litigation Proceeds Received c::>
8. Total Number of Safe Deposit Boxes
c::>
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
If 0 13 "
Firm Name (If Applicable)
o e Ii G ~
"1 I ..q.-
rl~ 3/31
City or Post Office
State
ZIP Code
REGISTER OF WILLS US~NLY
(") ".=::,
~Q CT'\
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First line of address
~ .;{ 1-
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l-C
R. 0 ,.4 0
Second line of address
--
...,...c'_
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W
Ni(3W
P,A
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4 I
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.
DATE
II - I - 0 ,
ADDRESS
E FOR FILING RETURN
I t'/~
e..l--leJ.sle Ifc/o) ^,.lj,AJ;,Ilfi~} ,/.1 /1';~'11 )
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ' ,
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056041046
15056041046
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15056042047
REV-1500 EX
Decedent's Name:
CLA'fi~ S.
CftL/{ /f'lS
RECAPITULATION
1. Real estate (Schedule A).
....................................... .
2. Stocks and Bonds (Schedule B) . . . . . . . . .
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . .
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . .
6. Jointly Owned Property (Schedule F) <=) Separate Billing Requested . . . . .
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) <=) Separate Billing Requested. . . . . .
1.
2.
4.
5.
6.
7.
Decedent's Social Security Number
)'71.A'-/ t/hCft
:;1.0
? C)
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . .
I
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .
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) . . .
. 9
10.
. . . . 14.
/
^ 8
.:;- Z (;
2...
I Sri 1-&~ g 2
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(12) X .0_
16. Amount of Line 14 taxabl~
at lineal rate X.O --#. 5' '[ 0
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 ....
15.
16
17.
18.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056042047
19.
o
<=)
15056042047
~
Kt:V-l :JUU t:" ~age j
File Number
Decedent's Complete Address:
DECEDENT'S NAME
C~A-/R8
J.. 'I.?-
3, CA-l,.}(,' NS
C fi/I u '5' '-'C Rei .
STREET ADDRESS
CITY
N G.w 1/i'II~
STATE
1'/1
ZIP
/1 d t/ I
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payment;;
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
1'1
1/ 0 ro. -
Total Credits ( A + B + C ) (2)
'f/ c?-tJ, ?!-
3. InteresUPenalty 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
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;...................................................................................... D D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D D
c. retain a reversionary interest; or.......................................................................................................................... D D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D 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 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 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. ~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.
REV-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 survivorship must be disclosed on Schedule F,
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX+ (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 2. Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
REV-1504 EX+ (1-97)
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1505EX + (1-97)
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
1. Name of Corporation
Address
City
2. Federal Employer I.D. Number
3. Type of Business
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
State
ProducUService
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting / Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? 0 Yes o No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? 0 Yes o 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 stock of this company 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 Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a written shareholder's agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
DYes
o No
10. Was the decedent's stock sold?
DYes
o 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.
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. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV-1506 EX+ (9-00)
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
1. Name of Partnership
Address
Date Business Commenced
Business Reporting Year
State
Zip Code
City
2. Federal Employer 1.0. Number
3. Type of Business
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
flARTNEANAME PERCENT PERCENT BALANCE OF
OF INCOME OF OWNERSHIP CAPITAL ACCOUNT
A.
B.
C.
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/so If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-1507 EX+ (1-97) \':
~.: 'J~"'& .
~
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-1508 EX + (1-97)
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
etA- I;' 6 .J'. CA- L/{ ( ,\IS
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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.
J..-
DESCRIPTION
U.<j'.
-
1,4 x.
l(a 4/1.1\1
(II/-^ ~"Ai)
VALUE AT DATE
OF DEATH
i.//s-. ~ 0
100. ;{ {;I
C /, v. cl< I~ /icei. in I d ,,(/t- l f
d If. fa. 0 t c&. ~ fA (:;. ~I f..; () (, )
)) ;led.
/y. f r It J..8$J}J8t.f
13 A-Ii!;t... f4.,rh;/t...J.4.
I
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
.fj6', ~
REV-1509 EX. (1-97)
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
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.
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY '10 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 DECO'S V AWE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1 A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV~ 1510 EX + (1-97)
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
,
et.A-hie ,1', CAA r<,'N5 --
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.
ITEM
NUMBER
1.
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
EXCLUSION
TAXABLE VALUE
(-ro 0) F-,'dv. /,:ry In d/v ,-duo1. ACe-+'
(j -ICj-Orc)
(1'00) C-\'deJ'{l
Ii 0 ~ I '" OCto( f,r< -drlO hILI.
f'v(a.-fadtS CA-W<'Jl.J-ddu
J". gee+! C4/,Kt,;vi tI -5c
n" lGULlt. -'-Nt
_ ~;';(;:1~t;.
('loo) VAN KAMpf'" .Ir\lvrsT/I16N IS
&0 ?S-B~I
I
8tf!1fc
B"7a
870
a ' .:II
60 ,5"8. -
/
(i-14 -D')
!:i
~o 1.13
/
frD ulD
S-o "it;
J'I
:<'D~ ?:j,3-
8ofJl/\l ocl<~-dJIl5Arli...
. ,'" - (]
lVt~;j L-1-/ k'lf5-dJtt
(i-I q -0(".)
.t.~ IJ I r.3
fJoCZ"
,?o '7c
1.3
~) i~ f. -
(T~i) ) DR f-y ~LAS
l~D8/(\.I ocllv -dd7ftit 02-
oj. tJ() *7" :l/ bb!i .-
:).,1) ~(.s:- ~
Ne....CJ2.dzS ('dIU.:x ~JcJ. bD?c
(To.o) EATON V4NCE (:;.. -Iq -(6)
110elN CCK4r--Ja" 99 !:;:jo <i7~ ~ Cf1S1f.
~'Vlen.zdA5 . I ~Ol 9-1S".- 5DQc " '
CGJ'K,~ -cM/A.
-----,-_.__.~-.,...
trOD) 13 E,LL- .sO~:'H "'-Ift-Ob) 3 1..118 ~
L_._..__u_....,.._..... (\Il~Jis C~~/~ - ..3 <{ I 8 ~.!? Iou '10 , .
I .
(-1oD) Vu ;z.oc-J ~ '^~+.r (f-,Q-06j
lo{> ct., :/-, q ~ I. ,':J-;l..
(vk~k.s G-u.~ - ~ 9;;11, fiJ...
clc1v5nfi\,
{rOO) AliI .s.NC. (; -'Iq-Db )
I l~t>i3l1\1 [)'l
Ockrz;- - c~ if (OOCle
& . ~ 89 Io/"a~-
) II . _
TOTAL (Also enter on line 7, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
(Ea _ ~1
v -,) '1tJc,. -
REV-1511 EX+ (12-99) "
~:~;t
"'4~.$>>
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
ttk'R~ S',
FILE NUMBER
eAi"k, 'Ns
Debts of decedent must be reported on Schedule l.
ITEM
NUMBER
A. FUNERAL EXPENSES:
1.
DESCRIPTION
CRt;tfA---;'o'" I VI/N1 CO~Or.'f.IJ./ DM-fI, &nf1;;'''1tJ".;
NEvJ:;fJPrPefl) CEAtfT"/1A.Y Fe~ MI5.MiJ,Q1.4-L ~Ai',t,
,DM{3~IDIVe ;
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6.
7.
("1- - 22 -0' )
(.E-
Tax Return Preparer's Fees (a 6c5' )T,4..~ Rt 11)/'11 PILL 1.<.)/ OF"" SW, us; C t: P
-....--.T---.-..
,MOM.S.
. /'t\ fftl eM ltlL ~. Ell v 1(.:J2
) Q_~ '/- Db)
w/cJtt//1..CIj) P~S-&r F~ )I1(111Uf'lit.. f..v(1CIf ri","'/K~
J / I-LQ~.
P/rl/J""': PI!. iJt?f or::- REVE,V UP V1-XES
/"IO,M. ~.
J.l-YNO~ ~/.} (TeI16: lv/Kill 6-'+$)
frJ
,';] FDI:ut.4-f1~>7
iWUJ
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
~ ,~ (;0. CO
I
f.r t'V
t" 4. IS
lL/t.trO
/.t-/'-I. Cf4
<25"':/8
~J8t.jS. ,):}
REV-1512 EX+ (12-03)
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-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
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 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+ (12-03)
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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
LIFE ESTATE INTEREST CALCULATION
NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS
DATE OF DEATH LIFE ESTATE IS PAYABLE
o Life or o Term of Years
o Life or o Term of Years
-
o Life or o Term of Years
-
o Life or o Term of Years
o Life or o Term of Years
1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table .................................................
Interest table rate - 031/2% 06% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
ANNUITY INTEREST CALCULATION
NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS
DATE OF DEATH ANNUITY IS PAYABLE
o Life or o Term of Years
-
o Life or o Term of Years
o Life or o Term of Years
o Life or o 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)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1)
o Monthly (12)
o 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 3 1/2% 06% 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions) ..................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Value of annuity - If using 3 1/2%, 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)
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
OCKER ROBIN W
227 CARLISLE ROAD
NEWVILLE, PA 17241
.__u___ fold
ESTATE INFORMATION: SSN: 278-24-4698
FILE NUMBER: 2106-1015
DECEDENT NAME: CALKINS CLAIRE S
DATE OF PAYMENT: 11/15/2006
POSTMARK DATE: 11/14/2006
COUNTY: CUMBERLAND
DA TE OF DEATH: 02/19/2006
Kt:V-1 IbL t:JI.\ I I-'='b}
NO. CD 007446
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $4,270.71
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$4,270.71
REMARKS: OCKER ROBIN W
CHECK# 1004
SEAL
INITIALS: AJW
RECEIVED BY:
RF(:;lc;TFR OF WII I S
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
KI:V-IIt:>L 1:^(.ll-~t:>J
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
~ECEIVED FROM:
OCKER ROBIN W
227 CARLISLE ROAD
NEWVILLE, PA 17241
_n_____ fold
ESTATE INFORMATION: SSN: 278-24-4698
FILE NUMBER: 2106-1015
DECEDENT NAME: CALKINS CLAIRE S
DA TE OF PAYMENT: 11/15/2006
POSTMARK DATE: 11/14/2006
COUNTY: CUMBERLAND
DA TE OF DEATH: 02/19/2006
NO. CD 007445
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,800.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,800.00
REMARKS: OCKER DANIEL R
CHECK# 3861
SEAL
INITIALS: AJW
RECEIVED BY:
RFGISTFR OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS