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NOTICE OF INHERITANCE TAX pennsylvan~a' ~
APPR~R~~~S~N-~., ~~L.~,.,QWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE ~`
BUREAU OF INDIVIDUAL TAXES ~~ ! ~ ~ -.-_.-.
INHERITANCE TAX DIVISION OF ~;D~~U~i'-SONS `',k~1~Llt'ASSESSMENT OF TAX REV-1547 EX AFP C12-09?
PO BOX 280601 ~ ~ ~` ~ ~ ' ~':;,`
HARRISBURG PA 17128-0601 ~ ~` `'~ ~ `'
~~~~Q~ ~$ P~ 2` DATE 11-01-2010
JESTATE OF GOUDY MARIE H
DATE OF DEATH 05-23-2010
~~,~~~ (;~' FILE NUMBER 21 10-0598
ORCO~"{~t,~`~ ~(l1,~~` COUNTY CUMBERLAND
WM D SCHRACK I I I C~~~~"~~~-~'1 ~; .! ~ ~ ACN 101
~~~'~ ~:~.~ , PA.
124 W HARRISBURG ST APPEAL DATE: 12-31-2010
D I L L S B U R G P A 17 019 (See reverse side under Objections )
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE _ -'~ R_ETA_IN LOWER POR_TION_ FOR YOUR RECORDS E-- _ ______________
REV-1547 EX AFP C12-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR -
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: GOUDY MARIE HFILE N0.:21 10-0598 ACN: 101 DATE: 11-01-2010
TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1) .0 0 NOTE: To ensure proper
2. Stocks and Bonds (Schedule B) C2) ,0 0 credit to your account,
.0 0 submit the upper portion
3. Closely Held Stock/Partnership Interest (Schedule C) C3) of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) .0 0 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 63, 1$2.09
6. Jointly Owned Property (Schedule F) ((,) .0 0
7. Transfers tSchedule G) (7) 234, 611.69
C8) 297 , 793.78
8. Total Assets
APPROV ED DEDUCTIONS AND EXEMPTIONS:
9. Funeral ExpenseslAdm. Costs/Misc. Expenses (Schedule H) C9) 16,18 0.8 0
10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) 14 7.7 2
C11) 16,328.52
11. Total Deductions C 12) 281 , 465.26
12.
13. Net Value of Tax Return
Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .0 0
14. Net Value of Estate Subject to Tax (14) 281 , 465.26_
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to d ate.
ASSESS MENT OF TAX:
15. Amount of Line 14 at Spousal rate C15) .0 0 X 0 0 = .0 0
16. Amount of Line 14 taxable at Lineal/Class A rate (lb) 781.465.26 x 045 12,665.94
17. Amount of Line 14 at Sibling rate C17) _D 0 X 12 .0 0
18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 15 = .0 0
19. Principal Tax Due C19)= 12, 665.94
TAX (_R FiITTS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID C-) AMOUNT PAID
08-19-2010 CD013239 631.58 12,000.00
08-30-2010 CD013287 .00 34.36
TOTAL TAX PAYMENT 12,b65.94
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~~
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