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NOTICE OF INHERITANCE TAX
r~ n~^~;~•;~}pp~'~ ~ T, ALLOWANCE OR DISALLOWANCE
BUREAU OF INDIVIDUAL TAXESI~L,~~,'~ ,~~F-.°>; '~ CTIONS AND ASSESSMENT OF TAX
INHERITANCE TAX DIVISION x~r"I;' ~'r '"i , ' ~~,
PO BOX 280601 ~!t _~ .~• • ~... t ',,;,- s ~ i_.~.V
HARRISBURG PA 17128-0601
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is ~ i ~ e. ~, ~ ~ ~ U , ~ ~.. ' ~ ~+'
CLERK ~F
OR~H~'S CaUnT
MICHAEL OHAR~~~.~~.:~~~ 11'x., FA
BOX 7544
400 MARYLAND DR
FT WASHINGTON PA 19034
pennsylvania ~
DEPARTMENT OF REVENUE ~•
REV-1547 IX AFP C12-10)
DATE 06-:13-2011
ESTATE OF MEJASICH MATTHEW
DATE OF DEATH 08-10-2010
FILE NUMBER 21 10-0850
COUNTY CUMBERLAND
ACN 101
APPEAL DATE: 08-12-2011
(See reverse side under Objections
Amount Remitted C
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
J
~ RETAIN LOWER PORTION FOR
--------------------
THIS LINE
CUT ALONG YOUR RECORDS ~'
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CE
O
A ______________
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OR
REV-154 _
_
7 EX AFP C12-10~ NOTICE
RDEDUCTIONS ANDR
N TAX
OF
ASSESSMENT
WANCE
OF
DISALLO
JFILE N0.:21 10-0850 ACN: 101
DATE: 06-13-2011
ESTATE OF: MEJASICH MATTHEW
TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
•0 0
NOTE: To ensure proper
1. Real Estate (Schedule A) C1)
,~ ~ credit to your account,
2. Stocks and Bonds (Schedule B)
C2)
.0 0
C3)
submit the upper portion
of this form with your
3. Closely Held Stock/Partnership Interest (Schedule C) .Q Q tax payment.
4.
Mortgages/Notes Receivable (Schedule D) C4)
25,799.54
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) .0 0
6.
Jointly Owned Property (Schedule F) C6)
613,412.14
7.
Transfers (Schedule G) C7)
211 .68
639
C8) ,
8. Total Assets
APPROV ED DEDUCTIONS AND EXEMPTIONS: 62
470
24
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) .
.
C9) 7 9 9.8 6
10.
Debts/Mortgage Liabilities/Liens (Schedule I) C10)
25, 270 .48
11 .
Total Deductions C11)
C12)
613, 941.20
12. Net Value of Tax Return
itable/Governmental Bequests; Non-elected 9113 Trusts (13)
(Schedule ~) .0 0
2 0
9 41
613
13. Char C14) .
,
14. Net Value of Estate Subject to Tax
15
14
'
n
and 19 will
~
NOTE: If an assessment was issued previously. lines ,
to
essed
s d te
ass
t fi ures that include the total of ALL return
reflec 9
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-)
10-21-2010 CD013544 1,473.68
03-31-2011 CD014245 .00
.00 x 00 = .00
C15)
C16) 590 .94'I _20 X 045 = 2b, 592.35
c17) .00 x 12 = .00
Ci8) 23,000.00 X 15 = 3,450.00
C19)= 30,042.35
AMOUNT PAID
28,000.00
568.67
TOTAL TAX PAYMENT 30,042.35
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.