1505614105 INHERITANCE TAX RETURN PO BOX 280601 RESIDENT DECEDENT Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW MMDDYYYY Social Security Number Date of Death Date of Birth REV-1500 Bureau of Individual Taxes EX (01-16) (FI) OFFICIAL USE ONLY County Code Year File Number MMDDYYYY 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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return 4. Agriculture Exemption (date of death on or after 7-1-2012) 7. Decedent Died Testate (Attach copy of will.) 10. Litigation Proceeds Received 13. Business Assets 2. Supplemental Return 5. Future Interest Compromise (date of death after 12-12-82) 8. Decedent Maintained a Living Trust (Attach copy of trust.) 11. Non-Probate Transferee Return (Schedule F and G Assets Only) 14. Spouse is Sole Beneficiary (No trust involved) 3. Remainder Return (date of death prior to 12-13-82) 6. Federal Estate Tax Return Required 9. Total Number of Safe Deposit Boxes 12. Deferral/Election of Spousal Trusts CORRESPONDENT ­ THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number First Line of Address Second Line of Address City or Post Office State ZIP Code Correspondent's email address: REGISTER OF WILLS USE ONLY REGISTER OF WILLS USE ONLY DATE FILED MMDDYYYY DATE FILED STAMP PLEASE USE ORIGINAL FORM ONLY Side 1 1505614105 1505614105 American LegalNet, Inc. www.FormsWorkFlow.com 1505614205 REV-1500 EX (FI) Decedent's Social Security Number 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 and Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E). . . . . . . 5. 6. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . . . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested. . . . . . . . 7. 8. Total Gross Assets (total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. Funeral Expenses and Administrative Costs (Schedule H) . . . . . . . . . . . . . . . . . . . 9. 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I). . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 and 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 CALCULATION - 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 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Under penalties of perjury, I declare 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 person responsible for filing the return is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN ADDRESS DATE DATE Side 2 1505614205 1505614205 American LegalNet, Inc. www.FormsWorkFlow.com REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: 1. 2. Tax Due (Page 2, Line 19) Credits/Payments A. Prior Payments B. Discount (See instructions.) Interest 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. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) Total Credits ( A + B ) (2) (3) 3. 4. (4) (5) 5. 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 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?.............. 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ No 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the