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INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
.. ,. _
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601 _ ~ ~~
HARRISBURG PA 17128-0601 `" .~ -' '~
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CARLISLE PA 17013-1252
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DEPARTMENT OF REVENUE e
REV-].604 EX AFP C12-09)
DATE 07-26-2010
ESTATE OF KELLER INA M
DATE OF DEATH 12-09-2009
FILE NUMBER 21 09-1175
COUNTY CUMBERLAND
SSN/DC 175-10-7404
ACN 10103407
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 ~--
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REV-1604 EX AFP C12-09~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 07-26-2010
ESTATE OF: KELLER INA M DATE OF DEATH: 12-09-2009 COUNTY: CUMBERLAND
FILE NO.: 21 09-1175 S.S/D.C. N0.:175-10-7404 ACN: 10103407
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: PNC BANK NA ACCOUNT NO.: 000031800163927
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING CX) TRUST C ~ TIME CERTIFICATE
DATE ESTABLISHED 09-02-1999
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 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" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
~•~~
REV-1470 EX (6-88)
a
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME FILE NUMBER
INA M KELLER 2109-1175
REVIEWED BY ACN
Judy Watts 10103407
ITEM
SCHEDULE NO, EXPLANATION OF CHANGES
The above ACN has been zeroed out leaving a zero balance due. This account was
reported and paid on the Inheritance tax return.
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