Social Security Number FILL IN APPROPRIATE OVALS BELOW 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Agriculture Exemption 5. Future Interest Compromise 6. Federal Estate Tax Return Required (date of death on or after 7-1-2012) (date of death after 12-12-82) 7. Decedent Died Testate 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) 10. Non-Probate Transferee Return 11. Spouse is Sole Beneficiary 12. Deferral/Election of Spousal Trusts (Schedule F and G assets only) (No Trust involved) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: StateCityFirst Line of AddressSecond Line of AddressZIP CodeDaytime Telephone NumberCorrespondent220s NameCHECK ONE: Flat Rate Proportionate Rate (Complete Part X on Page 3) REFER TO TAX COMPUTATION METHOD IN THE INSTRUCTIONS FOR FORM REV-1737-A. 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 PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS INTERNAL USE ONLY DATE FILED REV-1737-A Bureau of IndIvIdual Taxes Po Box 280601 HarrIsBurg, Pa 17128-0601Decedent220s Last NameSuffix Spouse220s Last Name Suffix Decedent220s First Name MI Spouse220s First Name MI OFFICIAL USE ONLY INHERITANCE TAX RETURN NONRESIDENT DECEDENT ENTER DECEDENT I NFORMATION BELOW (If Applicable) Enter Surviving Spouse220s Information Below (MM/DD/YYYY) Date of DeathDate of Birth(MM/DD/YYYY) PAGE 1 PART I 205 DECEDENT INFORMATION PART II 205 RETURN TYPE PART III 205 TAX COMPUTATION METHOD PART IV 205 CORRESPONDENT INFORMATION PART V 205 SIGNATURES File Number Correspondent220s Email Address17370181051737018105(EX) 09-18 (FI) 1737018105 American LegalNet, Inc. www.FormsWorkFlow.com Decedent220s Name: Social Security Number SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 15. 16. Amount of Line 14 taxable at lineal rate X .0 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 OVERPAYMENTFor dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. 2479116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. 2479116 (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 21 years of age or younger at death to or for the use of a natural parent, adoptive parent, or stepparent of the child is 0 percent [72 P.S. 2479116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent220s lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. 2479116 (a)(1.2) [72 P.S. 2479116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent220s siblings is 12 percent [72 P.S. 2479116(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.Street Address City State ZIP Code 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 Assets (Schedule F) Separate Billing Requested. . . . . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 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 and 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. PAGE 2 PART VI 205 DECEDENT ADDRESS PART VII 205 RECAPITULATION PART VIII 205 TAX CALCULATION 1737018205 1737018205REV-1737-A (EX) 09-18 (FI) 1737018205 American LegalNet, Inc. www.FormsWorkFlow.com 1. Total Pennsylvania real property and tangible personal property located in Pennsylvania................................................................................ (1) 2. Total gross assets wherever situated (Page 2 Line 8)............................................... (2) 3. Proportion (Divide Line 1 by Line 2).................................................................................................................... (3) 4. Total debts and deductions and amounts devised to charitable organizations (Add Page 2 lines 11 and 13).............................................................. (4) 5. Taxable Estate as if a Pennsylvania resident (Subtract Line 4 from Line 2)...................................................................................... (5) 6. Spousal transfers or transfers under Sec. 9116 (a)(1.2) Amount Taxable at % X Proportion (Line 3).......... X = (6) 7. Amount Taxable at lineal rate X Proportion (Line 3)............................................................ X = (7) 8. Amount Taxable at sibling rate X Proportion (Line 3)............................................................ X = (8) 9. Amount Taxable at collateral rate X Proportion (Line 3)............................................................ X = (9) Make checks payable to: COMMONWEALTH OF PENNSYLVANIADecedent220s Name: Social Security Number ANSWER THE FOLLOWING QUESTIONS IF THE PROPORTIONATE RATE METHOD IS ELECTED OR IF PENNSYLVANIA REALTY OR TANGIBLE PERSONAL PROPERTY LOCATED IN PENNSYLVANIA WAS TRANSFERRED WITHIN ONE YEAR OF THE DEATH OF THE DECEDENT. 1. Did decedent make a transfer and: Yes No 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?............................................................................................................................ d. receive the promise for life of either payments, benefits or care?...................................................................... 2.If death occurred after Dec. 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?............