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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
~~~ ~' ~~~~~`,~~ ~ ~;~~~~~;~',~~IHERITANCE TAX
R,~CORD ADJUSTMENT
j"~,L~~~,i'':r~.~"IlITiL'Y' HELD OR TRUST ASSETS
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO 80X 280601
HARRISBURG PA 17128-0601
209 SEP 18 PN 12~ 5
CLERK CF
QR~P''7w~r~~S COURT
GARY ENDRES CU"~r~LrF'!~~~rD i!n„ PA
275 EAST SPRING VALLEY
RD
DILLSBURG PA 17019
REV-1604 EX AFP (01-09)
DATE 09-04-2009
ESTATE OF FERNANDES JOSEPH
DATE OF DEATH 10-12-2008
FILE NUMBER 21 08-1164
COUNTY CUMBERLAND
SSN/DC 019-20-9330
ACN 09105003
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 ~
REV-1604 EX AFP (01-09)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE 09-04-2009
ESTATE OF FERNANDES JOSEPH DATE OF DEATH 10-12-2008 COUNTY CUMBERLAND
FILE N0. 21 OS-1164 S.S/D.C. N0. 019-20-9330
ACN 09105003
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: AMERICHOICE FCU ACCOUNT N0. 40156-18
TYPE OF ACCOUNT: (X) SAVINGS C ) CHECKING C ) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 04-24-2008
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 1.000
.00
_ .00
.00
X .15
.00
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
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 ,,,~
C IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A 'CREDIT" CCR), ~^~'J~)~~~/)
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
REV-1470 EX (6-88)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
INHERITANCE TAX
EXPLANATION
OF CHANGES
DECEDENTS NAME FILE NUMBER
Joseph Fernandes 2108-1164
REVIEWED BY ACN
Joan Peters 09105003
ITEM
SCHEDULE NO, EXPLANATION OF CHANGES
The above referenced Account Control Number has been adjusted do zero since the joint
bank account was reported on the Inheritance Tax Return„
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