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BUREAU OF INDIVIDUAL TAXES
NOTICE OF INHERITANCE TAX Pennsylvania
DEPARTMENT OF REVENUE ~
INHERITANCE TAX DIVISION 'APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
PO BOX 280601 t-r /?^~t'i~~ ~~ Q~ r AND ASSESSMENT OF TAX ON
~
` `
~ REV-1548 EX AFP C12-09)
HARRISBURG PA 17128-0601 °
`•`'
' JOTNfI HELD OR TRUST ASSETS
DATE 02-01 -201
ZAI~ FE8 - I PM I ~ 49
PATSY A MARTIN ~~~
167 OVERCASH RD ~~~~~~~~,.
CHAMBERSBURG PA 1 20
0
ESTATE OF HORN GLEN R
DATE OF DEATH 12-06-2009
FILE NUMBER 21 09-1213
COUNTY CUMBERLAND
SSN/DC 188-12-5666
ACN 09180616
APPEAL DATE: 04-02-2010
(See reverse side under Objections)
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS d-
REV-1548 EX AFP (12-09)--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE: 0 -01-2010
ESTATE OF: HORN GLEN R DATE OF DEATH: 12-06-2009
FILE NO.: 21 09-1213 S.S/D.C. NO.: 188-12-5666
COUNTY: CUMBERLAND
ACN: 09180616
TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: FARMERS 8~ MERCHANTS TRUST CO ACCOUNT NO.: 70-64365
TYPE OF ACCOUNT: CX)SAVINGS C ) CHECKING C )TRUST C )TIME CERTIFICATE
DATE ESTABLISHED 05-23-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
14,241.68
X 0.500
7,120.84
- .00
7,120.84
x .45
320.44
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
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE T0:
"REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
12-28-2009 CD012174 16.02 320.44
TOTAL TAX PAYMENT 336.46
BALANCE OF TAX DUE 16.02CR
INTEREST AND PEN. .00
TOTAL DUE 16.02CR
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. * Co.`s
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.