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Home My WebLink About06100COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT MELLON BNY PO BOX 193-0305 PHILADELPHIA, PA 19101-7899 fold ESTATE INFORMATION: ssrv: oo0-00-0000 FILE NUMBER: 2150- 6100 DECEDENT NAME: JACOBSON DAVID R DATE OF PAYMENT: 08/31 /2010 POSTMARK DATE: 08/26/2010 couNTY: CUMBERLAND DATE OF DEATH: 03/ 17/ 1950 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~ 58,558.27 TOTAL AMOUNT PAID: REMARKS: CHECK#11302454 SEAL INITIALS: CJ RECEIVED BY: 58,558.27 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 013278 REGISTER OF WILLS ,/ BNY MELLON BNY Mellon Wealth Management August 26, 2010 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle PA 17013 X387 RE: Estate of David R Jacobson DOD 03/17/50 Old File # 1630-16 Ladies and Gentlemen: N ,, ~ ` ~ ~ ~ , - r-~ c-'~ v~= T 3 N N Enclosed please find 2 copies of our Final Remainder Interest Inheritance Tax Return along with our check in the amount of $8,558.27. Please acknowledge receipt on the enclosed copy of this letter and return to me in the envelope provided. Sincerely, ~~~- Robert G Chase Tax Accountant (215)553-1047 1735 Market Street, P.O. Box 7899, Room 193-0305, Philadelphia, PA 19101-7899 ~ ~ (;~ ~q~ ,1 ~,., ~ /~~ ¢ d o Y /N OP .. .. ., _. ~ _ ....._.. O O Z OS did-rfD7 / /1P ¢JONO o _- - ` =7 J_ 2 ~ n' It~~ni ~~ C 7V~b. _; ~ -_: •nw _ ~ ~ M ~~ n W -; .... ~~~ ~ O ' w ~ x ,~ o H ~ e ~ _= _- i ~ ~ c P4 M O c+1 Wa O U ~'~'1 ~~ ~ ~ 3 0 ~ -^- U W ~ w cn a 0 0 W H i-] rl "~ H P4 P4 ~ -"'e ~ C!~ W ,`7. H ill 7 ~ U ~ ~ C tl WW - p4 U ~-+ U ['~ {t.~ ~ {~ ~~ ~ ~ ° i O ~ . ~~ =. Q ~ ~ ~~~ `D ~ ~ ~~, "-'" _ _' o o ----- r- z °° °' o ~ m ,~ o oo .~;, ~ a 4p~ _ W y m Q ~s3i ~ ~ ~ ~ _ N ~ ~ '~ r7"i O a~ ° a Y ~ ~ . ~~", z ,~ ~ ~_ /~/~ M ~ L m ~ 1505610101 REV-1500 ~ (o~-lo, `:' OFFICIAL USE ONLY PA Department of Revenue P~~ia County Code Year File Number Bureau of Individual Taxes INI•tERITANCE TAX RETURN ~j '~~~''~ PO BOX 2806oi a l ~O ~ ~ CJI.J Harrisburg, PA ~~u8-o6os RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMODYYYY 3-17-SO Decedent's Last Name Suffix Decedent's First Name MI Jacobson David R (If Applicable). Enter Surviving Spouse's Information Below Spouse's Last Name i Suffix Spouse's First Name MI __. _ . Spouse's Social Security Number - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Final O 1. Original Return O 2. Supplemental Return ~ 3. Remainder Return (date of death _.. ____ _. prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12.82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiil) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Robert G. Chase (215) 553-1047 • REGISTER OF WILLS USE ONLY First line of address rv _ _ _ _ _ ca Bank of New York Mellon '_'. e~ :~'~ ., x,. t _ .. Second line of address P+1 ~ ... ~_. ' ~` ` ~ PO Box 7899-#193-0305 t~ _. . City or Post Office State ZIP Code _. __ -- _ '-` ~" s.R ~~ Philadelphia PA 19101-7899 ~~ ~. ~ Y ~ ...II' A "~ { ' •• ` ~,..t ~ ~I ' r CorrespondsnYs e-mail address: robert.chaseQbnyrnellon.com ~'' Under penalties of perry, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RE ISLE FO FILING RN DATE ~! 6 --(d A00 ESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 1505610101 Side 1 1505610101 ,~ REV-1500 EX Decedent's Name: 1505610105 Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 86, 482.65 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. $6, 482.65 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 900.00 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 85, 582.65 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 85, 582.65 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES __ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 _ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate x . .10 85, 582.65 18. 8, 558.27 19. TAX DUE ......................................................... 19. $, 558.27 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side. 2 L 150561015 1505610105 J REV 1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME STREET ADDRESS CITY I STATE ~ ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments _ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 8, 558.27 Total Credits (A + B) (2) (3) (4) (5) 8, 558.27 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 0 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)j. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)J. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV.~s~o Ex• ~.aa~ COMMONWEALTH OF PENNSYlVAN1A .SCHEDULE ''G' INHERITANCE TAX RETURN RESIDENT DKEOENT TRANSFERS Fig NuMSER David R. Jacobson THIS SCN WUI.E MUST dE COMPLETED AND fIIED IF THE ANSWER TO ANY OF THE QUESTIO NS ON THE REVERSE SIDE OF T HE COVER SHEET it YES. ITEM NUMBER DESCRIPTION OF PROPERTY ( EXCLUSION TOTAL YALUE ( DECD. OF ASSET ' % DOLLAR VALUE OF DECEDENT'S INT. INTEREST 1. The life tenant of the David R. Jacobson Testamentary Trust, Salomon Jacobson, died on 2-17-10. Assets as of 2-17-10 per attached statement. ~ 86,482.65 Please note that no distributions have been made as of the date of this return. 4 I ~ __-__L ~ __. _ ~. _ TOTAL (Also ~nts- on ling 7, R~capitulotion) ~ S $6 , 4$2.65 (!f nwr~ spoc~ a nNd~d insorf odditiond sftwy of scn~ size.) ~ i Date o€ Death: 02!17/2010 Valuation Date: 02/17/2010 Processing Date: 08/16/2010 Shares Security or Par Description 1) 3332.04 CASH & CASH EQU2VALENTS (CASH) 2) 8399.052 BNY MELLON FDS TR (05569M657) BALANCED FD M Mutual Fund (as quoted by NASDAQ3 02/17/2010 Total Value: Total Accrual: Total: $86,482.65 Estate Valuation Estate of: JACOBSON DAVID R. CO-T!W Account: 10170197BN6 Report Type: Date of Death Number of Securities: 2 File ID: 0197BN6 Mean and/or Div and Int Security High/Ask Low/Bid Adjustments Accruals Value 9.90000 Mkt 3,332.04 9.900000 83,150.61 $86,482.65 $0.00 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.1.1) ~~. • ~, ~•. GOMMaNWEAtTM Of i~NNSYlVAN1A INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES, ADMINISTRAtIVE COSTS AND MISCELLANEOUS EXPENSES Pleose Print or Type ESTA?E Of FILE NUMISER David R. Jacobson ITEM DESCRlPT10N ~ ~ AMOUNT NUMBER I A. ~ Funeral Expen:ls: i 1. ' 8. I Ad~ni~istrative Costs: 1. ~ Personol Rsprosentotive Commissions _ i • C. i 8 Sodal Security Number of Personal Representotiw: Year Commissions paid - 2. Attorney Fee: 3. Family Exemption CloimaM Relationship Addross of Cloimcnt of decedent's death Street Addross City State Zip Code 4. Probate Fees Miscello~eous Expenses: 1. BIVY Mellon -Tax Preparation Fee 900.00 TOTAL (Also enter on line 9, Recapitulation) ~ S 900.00 {If more space is needed, insert odditiooal sheep of •an:e size. ) ~ ~ #EV~IS17 Ex• (2.q) 4~ ~ SCHEDULE J COMMONWEAtTN a kNNSTIVANIA BE N E FI C IAR 1 ES NWNMTANC! TA>T gTYRN Mf~lM pEE:lOlftt ESTATE OF David R. Jacobson FILE NUMBER NUME;ER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE A. ToxablE~ 8~gwsts: 1. Judith Magee Grandniece 1/2 Residue 2. Barbara Zimmerman Grandniece 1/2 Residue NUlNI~ER NAME AND ADDRESS OP BENEFICIARY B. ChoritobiEi and GovE~rnmE~ntal BE~qutsts: 1. TOTAL CHARITABLE ANC GOVERNMENTAL BEQUESTS (Also sintE~~ on (in• 13, R~copitulotion) I AMOUNT OR SHARE OF ESTATE (If n~eh spoco is nNdEid, i~sKf additional s1+E~ts of fOfl1ET si:o) .. BUREAU OF INDIVIDUAL TAXES ~ - IN'HE~~ ONCE TAX INHERITANCE TAX orvlsloN STATEMENT OF ACCOUNT PO BOX 280601 , HARRISBURG PA 17128-0601 -` '" "~ ,. , ROBERT G CHASE r` - --- `~° BANK OF NEW YORK MELLON PO BOX 7899-#193-0305 PHILADELPHIA PA 19101-7899 pennsylvania ~~ DEPARTMENT OF REVENUE i REV-1607 EX AFP C12-09) DATE 10-04-2010 ESTATE OF JACOBSON DAVID R DATE OF DEATH 03-17-1950 FILE NUMBER 21 50-6100 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT_ALONG THIS LINE _ ~ RETAIN LOWER PORTION FOR YOUR RECORDS _~ _ _ _ _ REV 1607 SEX AFP C12 09~ ~~~~~ *** INHERITANCE TAX STATEMENT~OF ACCOUNT ~ *** ~~~~ ~ ~~~ ~~~~ ~~~~~ ESTATE OF:JACOBSON DAVID R FILE NO.: 21 50-b100 ACN: 101 DATE: 10-04-2010 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-28-2010 PRINCIPAL TAX DUE: .00 PAYMENTS (TAX CREDITS): P DATE T I RNUMBER (INTEREST PENN PA D {-)I AMOUNT PAID TOTAL TAX PAYMENT I .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE 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. ,:.1i~ BUREAU OF INDIVIDUAL;TiAX~'S~ ~--~, ;. INHERITANCE TAX ~ i '; INHERITANCE TAX DIVISION - ~ !:'STATEMENT OF ACCOUNT PO BOX 280601 ~ ~ HARRISBURG PA 17128-0601 ~ ~ _ ,. ', ,. ~, ~;, ..:..~~ i ~. .,i. ROBERT G~ ~,~ ° ;",-; "~' ~ 3y„ BANK OF N 'W`~1~0'aK`'fiIEE`L0~•'~". PO BOX 7899-#193-0305 PHILADELPHIA PA 19101-7899 Pennsylvania ~ ~ DEPARTMENT OF REVENUE i REV-1607 EX AFP C12-09) DATE 11-29-2010 ESTATE OF JACOBSON DAVID R DATE OF DEATH 03-17-1950 FILE NUMBER 21 50-6100 COUNTY CUMBERLAND ACN 102 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE _ _~_- RETAIN LOWER PORTION FOR YOUR RECORDS ~ _ _ _ REV X1607 SEX AFPr C12 09~ ~ ~ ~ *** INHERITANCE TAX STATEMENT~OF ~ACCUUNT ~~*** ~~~ ~~~~~~ ~~~~ ~~~~~ ESTATE OF:JACOBSON DAVID R FILE N0.:21 50-6100 ACN: 102 DATE: 11-29-2010 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-22-2010 PRINCIPAL TAX DUE: 8,558.27 PAYMENTS (TAX CREDITS): P DATE T I RNUMBER (INTEREST/PEN PAID C-)I AMOUNT PAID I 08-26-2010 CD013278 ~ .00 8,558.27 TOTAL TAX PAYMENT 8,558.27 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE ~ .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE 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. NOTICE OF INHERITANCE TAX -" ,+/~rRaP~A-~.~EMENT, ALLOWANCE OR DISALLOWANCE -, BUREAU OF INDIVIDUAL TAXES _. -# INHERITANCE TAX DIVISION ' I7F DEB' 'IONS AND ASSESSMENT OF TAX PO BOX 280601 ;i~ - .. {yi ; ^~ HARRISBURG PA 17128-Ob01 "' .. ., ~~~~~' Q~~ -~ ~~ ILA D~ ~~, '~..L.,f ftl ~r(~ ROBERT G CHAS~U ~~"- ,`,.';,f~,, ,~~--~, ` ~~ ~' , ti_, ~ , BANK OF NEW YORK MELLON PO BOX 7899-#193-0305 PHILADELPHIA PA 19101-7899 pennsylvan~a ~~ ~ DEPARTMENT OF REVENUE REV-1547 EX AFP C12-09) DATE 11-29-2010 ESTATE OF JACOBSON DAVID R DATE OF DEATH 03-17-1950 FILE NUMBER 21 50-6100 COUNTY CUMBERLAND ACN 102 APPEAL DATE: 01-28-2011 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 RETAIN-LOWER-PORTION FOR CUT ALONG THIS LINE --- -------- YOUR RECORDS -------------- ~ ------ ----------------- -- ------------------------ REV-1547 EX AFP C12-09) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: JACOBSON DAVID RFILE N0.:21 50-6100 ACN: 102 DATE: 11-29-2010 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: REMAINDER RETURN 1. Real Estate (Schedule A) C1) .0 0 NOTE: To ensure proper (2) ,0 0 credit to your account, 2. Stocks and Bonds (Schedule B) submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .0 0 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) (5) .0 0 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G) C7) 86,482.65 c8) 86 , 482.65 8. Total Assets APPROV ED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 9 0 0.0 0 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .0 0 C11) 900.00 11. Total Deductions 582.65 85 12. Net Value of Tax Return C 12) , 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .0 0 14. Net Value of Estate Subject to Tax (14) 85,582.65 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 asses sed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .0 0 X 0 2 = .0 0 16. Amount of Line 14 taxable at Lineal/Class A rate C16) _0 0 X 0 2 = .0 0 17. Amount of Line 14 at Sibling rate (17) .0 0 X 0 0 = .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 85,582.65 X 10 = 8,558.27 19. Principal Tax Due (19)= 8,558.27 TAY f'RFTITTS PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT PAID 08-26-2010 CD013278 .00 8,558.27 TOTAL TAX PAYMENT 8,558.27 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. .. ~~