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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIYISION
PO BOX 288681
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
r,~_r-,r.,-r> ~•~r.,.,~.I_ ^' INHERITANCE TAX
~~,~ "t „~: -...:RECORD ADJUSTMENT
2~~8 SEP -5 PM 12~ 51
CLERK ~F
MICHAEL CHEREWKA E~~"~A_?^' ~ ~f r_';^; , ~~
M CHEREWKA LAW OFFICES
624 N FRONT ST
WORMLEYSBURG PA 17043
REY-1593 EX AFP (03-D5)
DATE 0li-29-2008
ESTATE OF DE.RICKSON MELVA A
DATE OF DEATH 02-11-2007
FILE NUMBER 2]l 07-0225
COUNTY ClMBERLAND
ACN 101
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, submit the upper portion of :his form with your tax payment.
CUT ALONG THIS LINE ~) RETAIN LOWER PORTION FOR YOUR RECORDS ~---
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REV-1593 EX AFP C03-05~ ** INHERITANCE TAX RECORD ADJUSTMENT **
ESTATE OF DERICKSON MELVA A FILE N0. 21 07-0225 A(:N 101 DATE 08-29-2008
ADJUSTMENT BASED oN: ADMINISTRATIVE CORRECTION
VALUE OF ESTATE:
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT F'AID
11-13-2007 (0008955 .00 80,784.00
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
(1) .00
(2) .00
(3) .00
(4) .00
(5) 500.00
(6) .00
(n 1,150,690.00
(8)
1,151,190.00
(9) 57,765.00
(lo) 6,308.00
cll) 64, 073.00
Net Value of Tax Return (12) 1 , 087, 117.00
Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule .I) (13) 548,559.00
Net Value of Estate Subject to Tax (ly) 538,558.00
15. Amount of Line 14 at Spousal rate (15) . 00 X 00 = . 00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) .00 X 045= .00
17. Amount of Line 14 at Sibling rate (17) . 00 X 12 = . 00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) 538,558.00 X 15 = 80,783.70
19. Principal Tax Due (19) 80,784.00
TAX CREDITS:
12
13
14
TAX:
8. Total Assets
DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Administrative Costs/
Miscellaneous Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
BALANCE OF UNPAID INTEREST/PENALTY AS OF 11-14-2007
TOTAL TAX CREDIT 80,784.00
BALANCE OF TAX DUE .00
INTEREST ANI) PEN. 35.38
TOTAL DIIE 35.38
~ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. (-~
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE 01= THIS FORM FOR INSTRUCTIONS.) ~