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INHERITANCE TAX
RECORD ADJUSTMENT pennsylvan~a ~
JOTNTJ,..Y HELD OR TRUST ASSETS
BUREAU OF INDIVIDUAL TAXES ""•'``r~ `~~-•`'' r __T~'S~-- ~ DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION -- REV-16D4 IX AFP (12-09)
PO BOX 280601 -%~ _ '
HARRISBURG PA 17128-0601 ,._.~ ~ -~ `-~' ~~ ~ -
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CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
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REV-1604 EX AFP (12-09~
*~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 01-15-2010
ESTATE OF: COOPER KARL W DATE OF DEATH: 04-15-2007 COUNTY:
CUMBERLAND
FILE NO.: 21 07-0761 S.S/D.C. N0.:174-20-6412 ACN: 09143005
ADJUSTMENT BASED ON : ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: INTEGRITY BANK ACCOUNT NO.: 1005833
~_
DATE 01-15-2010
ESTATE OF COOPER KARL W
DATE OF DEATH 04-15-2007
FILE NUMBER 21 07-0761
COUNTY CUMBERLAND
SSN/DC 174-20-6412
ACN 09143005
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SgUARE
CARLISLE PA 17013
TYPE OF ACCOUNT: C ~ SAVINGS C ~ CHECKING C ~ TRUST CX) 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
X 1.000
.00
- .00
.00
X .045
.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 I RECEIPT
DATE 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" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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