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INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES-• - ~ _ ,~ ~~ RECORD ADJUSTMENT
INHERITANCE TAX DIVISION ~ ~ i,
Po eox 280601 , ~: ,-#ENEFICIARY FORM ASSETS
HARRISBURG PA 17128-0601 _: ~ ; `~.,.? • --
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JOHN J MITCHE u~iJ~~~r``~'~;-' i,~,~~~t~(
839 R I DGEWOOD DR I V .iti t '- -- ` r,
MECHANICSBURG PA 17050-0000
pennsylvan~a ~=- ~
DEPARTMENT OF REVENUE ~
REV-1604A EX AFP (01-10)
DATE 08-13-2010
ESTATE OF MITCHELL GERTRUDE I
DATE OF DEATH 02-17-2009
FILE NUMBER 21 09-0294
COUNTY CUMBERLAND
SSN/DC 204-18-0883
ACN 09503418
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-1604A EX AFP C12-09~
** INHERITANCE TAX RECORD ADJUSTMENT BENEFICIARY FORM ASSETS **
DATE: 08-13-2010
ESTATE OF: MITCHELL GERTRUDE I DATE OF DEATH: 02-17-2009 COUNTY: CUMBERLAND
FILE N0.:21 09-0294 S.S/D.C. NO.: 204-18-0883 ACN: 09503418
ADJUSTMENT BASED ON • ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: STIFEL NICOLAUS
TYPE OF ACCOUNT: (X) SECURITIES ( ) SEC ACCT ( ) STOCK
DOD Valuation
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Due
Tax Rate
TAX CREDITS:
.00
X O.lbb
.00
_ .00
.00
X .045
.00
ACCOUNT NO.: 5385-3049
( ) BOND
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 DISCDUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
05-13-2009 CD011234 .00 2,777.9b
TOTAL TAX PAYMENT 2 777.9b
BALANCE OF TAX DUE
INTEREST AND PEN. .00
TOTAL DUE 2,777.9bCR
* 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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1 k
RE`/-1470 EX (8-88)
INHERITANCE TAX
COMMONWEALTH OF PENNSYLVANIA EXPLANATION
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME FILE NUMBER
GERTRUDE I MITCHELL 2109-0294
REVIEWED BY
Judy Watts AcN 09503418
ITEM
SCHEDULE Np, EXPLANATION OF CHANGES
The above ACN has been zeroed out leaving a zero balance due. This account has been
reported and paid on the Inheritance tax return.
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