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INHERITANCE TAX
BUREAU DF INDIVIDUAL TAXES ,~ RECORD ADJUSTMENT
r,. ,, ; JOI,N.T4,Y ~LD OR TRUST ASSETS
INHERITANCE TAX DIVISION ~ ~-
PO BOX 280601 _
HARRISBURG PA 17126-0601 - - ~~`
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CHARLOTTE M SAKSA I '~_ ~~ ~ ~ ', i ""'i~
969 CHARTERHOUSE CT `
WESTERVILLE OH 43081-2763
Pennsylvania' _
DEPARTMENT OF REVENUE
REV-1604 EX AFP (12-10) -~~
DATE 08-18-2011
ESTATE OF POZSGAY
DATE OF DEATH 10-29-2010 MADELINE M
FILE NUMBER 21 11-0042
COUNTY CUMBERLAND
SSN/DC 163-44-4552
ACN 10170473
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE y RETAI
_______________________ N L O W E R P O R T I O N F
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REV-1604 EX AFP C12-10) O R
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-- -0 U R R E C O R DS F~
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** INHERITANCE TAX
RECORD ADJUSTMENT JOINTLY _
------------------ ___________
H ELD OR TRUST ASSETS **
ESTATE OF:
POZSGAY DATE: 08-18-2011
MADELINE M DATE OF DEATH:
10-29-2010 COUNTY:
FILE NO.: 21 11-0042 CUMBERLAND
ADJUSTMENT BASED ON: S.S/D.C. N0.:163-44-4552
ADMINISTRATIVE CORRECTION ACN:
10170473
FINANCIAL JOINT OR TRUST ASSET INFORMATION
INSTITUTION: FIRST NIAGARA BANK
ACCOUNT NO.: 4160375189
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING C ) TRUST
DATE ESTABLISHED CX)
05-09-2006 TIME CERTIFICATE
Account Balance
Percent Taxable
X 37,688.83 NOTE:
0
500 TO ENSURE PROPER CREDIT
Amount Subject to Tax
Debts
d
.
18,844.42 TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
an
Deductions
-
Taxable Amou
t .00 OF THIS NOTICE WITH YOUR TAX
n
Tax Rate
18,844.42 PAYMENT TO THE REGISTER OF WILLS
X
Tax Due
•045 AT THE ADDRESS SHOWN ABOVE.
TAX CREDITS:
848.00 MAKE CHECK OR MONEY ORDER PAYABLE
TO: "REGISTER
OF WILLS, AGENT."
PAYMENT RECEIPT
DATE NUMBER
DISCOUNT (+)
~~
01-07-2011
CD013873 INTEREST/PEN PAID (-) AMOUNT PAID
42.40
805.60
TOTAL TAX PAYMENT
BALANCE OF TAX DUE 848.00
INTEREST AND PEN. •00
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREOTALF DDUAL DUE IS REFLECTED AS A00
"CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
bH
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j,`, _'°'~ EX "71_,'
~ pennsylvania
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME
MADELINE M POZSGAY
SCHEDULEI ITEM
NO.
Robin Graff
INHERITANCE TAX
EXPLANATION
OF CHANGES
FILE NUMBER
2111-0042
10170473
EXPLANATION OF CHANGES
A daughter is a lineal heir and is taxable at the rate of 4.5%; therefore the tax rate has been
changed on the above A C N.
ROW
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