HomeMy WebLinkAbout06-21-10- _ _ _ _ ~ ~_
REV-1162 EXI11-96)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601 PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAZEN DAVID B
1622 QUAKER LANE
SALEM, OH 44460
ACN
ASSESSMENT
CONTROL
NUMBER
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ESTATE INFORMATION:
FILE NUMBER: SSN: 269-18-4996
2109-0888
DECEDENT NAME: HAZEN GERALDINE M
DATE OF PAYMENT: 06/ 21 / 2010
POSTMARK DATE: 06/18/2010
couNTY: CUMBERLAND
DATE OF DEATH: 09/20/2009
REMARKS:
SEAL
CHECK# 1014
TOTAL AMOUNT PAID:
INITIALS: SAP
RECEIVED BY:
REGISTER OF WILLS
NO. CDI 012959
~~
/MOUNT
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3, 864.39
GLENDA EARNER SI~RASBAUGH
REGISTER OF WILLS''
INVENTORY
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVA1~fIA
COIvIIrIONRIFALTH OF PENNSYLVANIA 1 ~S
COUNTY OF f
File Number
Personal Reprosentativo(s) of the Estate of C~LIiALC)tIVE M. rtA~Cly
decxasod, depose(s) and say(s) that the items appearing in the following inventory. incltde all of the persona! assets
and all of the real esmte in die Commonwealth of Pennsylvania of said Decedent, that the valuation placid opposite
inventory represents its fair value as of the date of the decedent's dealt, and that Decedent owned no real estate out'
Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory.
I verify that the statements made in this Inven-
tory are true and correct. I understand that false state-
ments herein are made subject to the penalties of
18 Pa. C.3. § 4904 relating to tmsworn falsification to
atrthorities.
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Attorng -- (Nm»e) n'-"'irl !'!_ R'-uir~~lf. E3a. _ (3uprene E'ourr I.b.
(Address}
(Telephone)
;never situate
h item of said
of the
owe oa o~-T-+ usr ~aio~et:
4905 East TrincBe Road
PA 17050 oEC.eotzars
269-1 .sec. rte.
FIGURES MUST BE TOTALED
Y ~~ Rt3furxl 747.08
Norfftnip Gnlmman - Retum Inwratttx Pretnitmt I
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95.28
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842.36
NCri'E: The Memortmaum of td! mtaro oseside the Comntonaralth at Pem-sylvaoia may, rt the election d the pereond ,epmsmtatlve include t~ vdue of ach
item, tot such figures should not be extended into the fatal of the Inventory. (Ste 20 Pa. CS. § 3301(b))
Form RN'-09 rev. 10.13.06
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