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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX OIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
("CC!"l'NHERITANCE TAX
',j!' .~fcORD ADJUSTMENT
'IJOlN'rLY iH)::LD OR TRUST ASSETS
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REV-1604 EX AFP (03-05)
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KATHLEEN GALLACHEtlF,
719 BARBARA ST
NEW CUMBERLAND PA 17070
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DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
11-20-2007
BURKE
10-18-2006
21 06-0968
CUMBERLAND
128-20-6360
06161284
JOSEPHINE A
2007 DEe -5 PM 12: 35
Amount Remi tted
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 11-20-2007
ESTATE OF BURKE
JOSEPHINE A DATE OF DEATH 10-18-2006
COUNTY
CUMBERLAND
FILE NO.
21 06-0968
S.S/D.C. NO. 128-20-6360
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
ACN
06161284
ADJUSTMENT BASED ON:
FINANCIAL INSTITUTION: MEMBERS 1ST FCU
ACCOUNT NO.
263033-00
TYPE OF ACCOUNT: (X) SAVINGS () CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 04-12-2005
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
* 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).
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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.
REV-1470 EX (6-88)
'* INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENrS NAME FILE NUMBER
Josephine A Burke 2106-0968
REVIEWED BY ACN
Rick Olson 06161284
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
The above referenced ACN has been reduced to zero as this account was reported on the
probate return.
PaQe 1