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INHERITANCE TAX
RECORD ADJUSTMENT
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BUREAU OF INDIVIDUAL TAXES -- _ _ -
INHERITANCE TAX DIVISION ,.~ --
PO BOX 280601 r , ~J i -, ~ -
HARRISBURG PA 17128-0601
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504 HUMMEL AVENUE
LEMOYNE PA 17043
Pennsylvania ~
DEPARTMENT OF REVENUE
REV-1604 IX AFP (12-09)
DATE 01-14-2010
ESTATE OF STROM NEIL L
DATE OF DEATH 03-26-2009
FILE NUMBER 21 09-0324
COUNTY CUMBERLAND
SSN/DC 396-46-7930
ACN 09006703
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SgUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
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REV-1604 EX AFP C12-09~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 01-14-2010
ESTATE OF: STROM NEIL L DATE OF DEATH: 03-26-2009 COUNTY: CUMBERLAND
FILE NO.: 21 09-0324 S.S/D.C. N0.:396-46-7930 ACN: 09006703
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: lsoo HUNTERS DRIVE ACCOUNT N0.: MECHANISBURG
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING C ) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 12-08-1995
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.500
.00
.00
.00
X .15
.00
NOTE: TO ENSURE 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 PAYMENT .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 REFLECTED AS A
"CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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