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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
pennsytvan~a ~'~=
DEPARTMENT OF REVENUE
REV-1604 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 10103405
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
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LARRY BISTLINE
217 E GARFIELD ST
SHIPPENSBURG PA 17257-2001
CUT ALONG THIS LINE --~ RETAIN LOWER PORTION FOR YOUR RECORDS E--~
REV-1604 EX AFP C12-09~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY NELD OR TRUST ASSETS **
DATE: 07-26-2010
ESTATE OF: KELLER INA M DATE OF DEATH: 12-09-2009 COUNTY: CLMBERLAND
JDINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: PNC BANK NA ACCOUNT NO.: 000031400255537
FILE NO.: 21 09-1175 S.S/D.C. N0.:175-10-7404 ACN: 1[1103405
ADJUSTMENT BASED ON : ADMINISTRATIVE CORRECTION
TYPE OF ACCOUNT: ( ) SAVINGS t ) CHECKING CX) TRUST C ] TIME CERTIFICATE
DATE ESTABLISHED 02-01-2005
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
INHERITANCE TAX
~, 1~ CORD ADJUSTMENT
~;` JOIN~TL~~~HELD OR TRUST ASSETS
. ;,
~i~~~ ~~,~~ --~ Sri 12~ ~8
.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 (+)
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.
+s
REV-1470 EX (6-88)
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 10103405
ITEM
SCHEDULE Np, 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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