Schedule C-Sb (Form Rev-571 C-Sb) - Small Business Exemption

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REV-571 C-SB (4-14)
Schedule C-SB
Small Business
BUREAU OF INDIVIDUAL TAXES
Exemption
ESTATE OF:
FILE NUMBER:
This schedule may be used only by estates of decedents dying after July 1, 2013.
Use this schedule to report a business interest for which you claim an exemption from inheritance tax
under the Qualified Family-Owned Business Exemption (72 P.S. §9111(t)).
Provide the following information along with Schedule C-SB. Failure to provide the following
information may result in a denial of the exemption or a delay in processing.
• Attach a written statement explaining in detail how the business interest qualifies for the exemption.
• Attach all documents supporting the written statement, including the valuation of the net book value and
business balance sheet.
MM/DD/YYYY
BUSINESS INFORMATION
BUSINESS NAME:
BUSINESS EIN:
DATE ESTABLISHED:
PHYSICAL LOCATION: STREET ADDRESS
NUMBER OF EMPLOYEES:
CITY
NET BOOK VALUE:
STATE
ZIP CODE
VALUE AT DATE OF DEATH
:
(UNDER 72 P.S. § 9121)
OWNER INFORMATION
Provide the name and mailing address of all transferees of the business interest identified above (attach additional
sheets if necessary):
OWNER NAME
RELATIONSHIP TO DECEDENT
OWNER NAME
RELATIONSHIP TO DECEDENT
MAILING ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
OWNER NAME
RELATIONSHIP TO DECEDENT
OWNER NAME
RELATIONSHIP TO DECEDENT
MAILING ADDRESS
MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
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