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BUREAU'O~ l~IVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 2B0601
HARRISBURG fA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
. .UU:lERITANCE TAX
RECORD ADJUSTMENT
~ JOINTLY HELD OR TRUST ASSETS
*'
REV-~604 EX AFP (03-05)
;, 1 ~ i: :3 (J,
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
04-16-2007
STAIVISKY
06-29-2006
21 07-0235
CUMBERLAND
193-30-1145
06147902
JAlCK
A
JERRY W STAIVISKY ,'..
420 NE 17TH AVE . .
BOYNTON BEACH FL 33435
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAY~ENT TO:
REGISTER OF WILLS !
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
+-
-----------------------------------------------------------------------------------------------------------------------------------------------,.-----------------
REV-1604 EX AFP (03-05)
~~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~
DATE 04-16-2007
ESTATE OF STAIVISKY
JACK
A DATE OF DEATH 06-29-2006
COUNTY
CUMBERLAND
FILE NO. 21 07 - 0235
ADJUSTMENT BASED ON:
S.S/D.C. NO. 193-30-1145
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
ACN
! 06147902
FINANCIAL INSTITUTION: THE MUNCY BANK & TRUST CO
ACCOUNT NO.
220500~815
TYPE OF ACCOUNT: (X) SAVINGS () CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 06-13-2005
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
5,274.07
0.166
879.02
.00
879.02
.12
105.48
NOTE:
TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UptER PORTION
OF THIS NOTICE WITH YO~R TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A~OVE.
MAKE CHECK OR MONEY ORbER PAYABLE
TO: "REGISTER OF WILLS. AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST /PEN PAID (-) /
03-06-2007 CD007890 .00 v 210.97
04-13-2007 REFUND .00 105.49-
TOTAL TAX CREDIT 105.48
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE nn
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), c::::)-
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) 0