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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
it(l:lERITANCE TAX
RECDRD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 1712B-0601
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ROGER A KOHR
4405 ROYAL OAK RD
CAMP HILL PA 17011
CUT ALONG THIS LINE
REV-160~ EX AFP (03-05)
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
01-17-2008
FETTERHOFF
10-16-2006
21 06-0951
CUMBERLAND
207-26-0248
06159497
BETTY
J
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
~
------------------------------------------------------------------------------------.-------------------...-----------.--------.-.-------....--------...----------
REV-1604 EX AFP (03-05)
-- INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS __
DATE 01-17-2008
ESTATE OF FETTERHOFF
BETTY
J DATE OF DEATH 10-16-2006
CUMBERLAND
FILE NO.
21 06-0951
COUNTY
ADJUSTMENT BASED ON:
S.S/D.C. NO. 207-26-0248
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU
ACN
06159497
ACCOUNT NO.
9398-47
TYPE OF ACCOUNT: () SAVINGS () CHECKING () TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 04-24-1967
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
.45
.00
TAX CREDITS:
PAYMENT
DATE
RECEIPT
NUMBER
DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
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."
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.)
C'o
.
REV-1470 EX (6-88)
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
Betty J Fetterhoff
FILE NUMBER
Rick Olson
ACN
2106-0951
06159497
REVIEWED BY
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