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BUREAU OF INDIVIDUAL TprX~S:~ "~ NOTICE OF INHERITANCE TAX
INHERITANCE TAX DIVISION '-' ~'` ' "` - x 'APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS
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LEONARD BOURINSKI
1171 BOILING SPRINGS RD
MECHANICSBURG PA 17055
pennsyLvania ~ ~ F
DEPARTMENT OF REVENUE
REV-1548 EX AFP (12-09) r
DATE 11-15-2010
ESTATE OF BOURINSKI JOYCE
DATE OF DEATH 12-03-2009
FILE NUMBER 21 10-0002
COUNTY CUMBERLAND
SSN/DC
ACN 09180000
APPEAL BY DATE:O1-14-2011
(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 --~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV-1548 EX AFP C12-09~--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE: 11-15-2010
ESTATE OF:BOURINSKI JOYCE DATE OF DEATH:12-03-2009
COUNTY:CUMBERLAND
FILE NO.: 21 10-0002 S.S/D.C. NO.: ACN: 09180000
TAX RETURN WAS: CX1 ACCEPTED AS FILED C ) CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 190278-00
TYPE OF ACCOUNT: CX3SAVINGS C ) CHECKING C TRUST C )TIME CERTIFICATE
DATE ESTABLISHED 01-14-2000
Account Balance 947.14 NOTE: TO ENSURE PRIJPER CREDIT TO
Percent Taxable X 0.166 YOUR ACCOUNT, SUBMIT THE
Amount Subject to Tax 157.86 UPPER PORTION OF THIS NOTICE
Debts and Deductions - .00 WITH YOUR TAX PAYMENT TO THE
Taxable Amount 157.86 REGISTER OF WILLS AT THE
Tax Rate x .00 ABOVE ADDRES`.3. MAKE CHECK
Tax Due .00 OR MONEY ORDER PAYABLE T0:
"REGISTER OF WILLS, AGENT."
TAX CREDITS:
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 .00
* 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.
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