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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
,~Jol-"r[Y HELD OR TRUST ASSETS
*'
,...
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
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THOMAS L VERNON
1001 DALE PL 0[ ".,
CARLISLE ~ii. i 7013 .
REV-1604 EX AFP <03-05)
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
03-15-2007
VERNON
04-27-2006
21 06-0637
CUMBERLAND
001-20-4367
06131005
JOYCE
T
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT 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 03-15-2007
ESTATE OF VERNON
JOYCE
CUMBERLAND
T DATE OF DEATH 04-27-2006
COUNTY
ACN
FILE NO. 21 06-0637
ADJUSTMENT BASED ON:
S.S/D.C. NO. 001-20-4367
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ORRSTOWN BANK
06131005
ACCOUNT NO.
106002056
TYPE OF ACCOUNT: () SAVINGS (X) CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 05-31-2001
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
.00
0.500
.00
.00
.00
.15
.00
TAX CREDITS:
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
TO: "REGISTER OF WILLS, AGENT."
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 00
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $I, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~
REv.IIEX (~)
.
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG. PA 17128-0601
DECEDENTS NAME
FILE NUMBER
REVIEWED BY
ACN
2106-0637
06131005
Joyce T Vernon
Department of Revenue I Teresa Seiders
ITEM
SCHEDULE NO.
EXPLANATION OF CHANGES
Above-referenced ACN(s) are being adjusted to reflect zero tax due since they have
been reported on the probate return.
ROW
PaQe'