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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
~r~~,^.,,?'~~t~ i ;`~-~~~ 1- ' INHERITANCE TAX
RECORD ADJUSTMENT
r,,,.~ ,.
i~_~; ", `.J:DINTLN HELD OR TRUST ASSETS
209 OCi _g ~~ I1 ~ 23
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ELF; ~~,{, ~ r
n~,~'''_ t i'~ 1~T
KARL E COOPER ~~ "` r ~'- ar.
16 LACOSTA AVE SM29 M14
CANCUN QR00 77508
MEXICO OC 99999
REV-1604 EX AFP CO1-09)
DATE 10-05-2009
ESTATE OF COOPER KARL W
DATE OF DEATH 04-15-2007
FILE NUMBER 21 07-0761
COUNTY CUMBERLAND
SSN/DC 174-20-6412
ACN 08137219
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS 4-
REV-1604 EX AFP (O1-09)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE 1005-2009
ESTATE OF COOPER KARL W DATE OF DEATH 04-15-2007 COUNTY CUMBERLAND
FILE N0. 21 07-0761 S.S/D.C. N0. 174-20-6412 ACN 08137219
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: INTEGRITY BANK ACCOUNT N0. 1005833
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING C ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 05-25-2006
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00 NOTE:
X 1.000
.00
- .DO
00
X .45
.00
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
T0: "REGISTER OF WILLS, AGENT.•'
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID C-) AMOUNT PAID
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.
C YOUTMAYLBEUDUESALREFUNDAN SEE REVERSEESIDESOFETHISEFORM FORFINSTRUCTIONSS)REFLECTED AS A'',"CREDIT" (CR), (~