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INHERITANCE TAX
RECORD ADJUSTMENT
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BUREAU OF INDIVIDUAL TAXES - .,,;;~
INHERITANCE TAX DIVISION .. ,~,. _,; .,~ _;.
PO BOX 280601
HARRISBURG PA 17128-0601
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DIANE SWINEHART~`~ ' - _ ' '
125 YORK STREET
WELLSVILLE PA 17365
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DEPARTMENT OF REVENUE
REV-11104 EX AFP (12-09)
DATE 09-27-2010
ESTATE OF STAMBAUGH DOROTHY L
DATE OF DEATH 07-15-2009
FILE NUMBER 21 09-0831
COUNTY CUMBERLAND
SSN/DC 189-18-5561
ACN 09152135
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 F~
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REV-1604 EX AFP C12-09)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE• 09-27-2010
ESTATE OF: STAMBAUGH
FILE NO.: 21 09-0831
DOROTHY L DATE OF DEATH: 07-15-2009 COUNTY:
S.S/D.C. N0.:189-18-5561
ACN:
CUMBERLAND
09152135
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 296654-11
TYPE OF ACCOUNT: ( ) SAVINGS CX) CHECKING C ) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 12-04-2006
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TOX CREDITS:
.00
X 0.500
.00
_ .00
.00
X .045
.00
NOTE: TO ENSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT 1-HE UPPER PORTION
OF THIS NOTICE W1:TH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SFIOWN ABOVE.
MAKE CHECK OR MOMEY ORDER PAYABLE
T0: "REGISTER OF= WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) 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.
c-I-
REV-1470 EX (01-10)
~ enns Lvania INHERITANCE TAX
p y
DEPARTMENT OF REVENUE EXPLANATION
BUREAU OF INDIVIDUAL TAXES OF CHANGES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME FILE NUMBER
DOROTHY L STAMBAUGH 2109-0831
REVIEWED BY
Robin Graff
09152135
SCHEDULE INO EXPLANATION OF CHANGES
A review has been conducted on this account. The Department has determined that this
joint bank account was properly reported on the probate return. Therefore, this
assessment has been corrected.
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