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BUREAU OF INDIVIDUAL TAXES ~I-~~~~~I~ r '`~~. T OF INHERITANCE TAX Pennsylvania ~
INHERITANCE TAX DIVISION r /~ppRA-ZS~~~ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE
PO BOX 260601 ~Li7',,;iO;F''D~pU~)b!fQI~S, AND ASSESSMENT OF TAX ON R~-1548 EX AFP C12-lo)
HARRISBURG PA 1 7128-0 60 1 ~ JOINTt~'J HELD OR TRUST ASSETS
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GAIL GREEN Ct~~~~',;=:L,{°,~~~; ,r`~~ p~
119 CALAMAN RD
CRANSTON RI 02910-4230
DATE 11-07-2011
ESTATE OF POLLAK JEFFREY D
DATE OF DEATH 01-03-2011
FILE NUMBER 21 11-0779
COUNTY CUMBERLAND
SSN/DC 087-36-4142
ACN 11139217
APPEAL BY DATE:O1-06-2012
(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 E'-
REV-1548 EX AFP C12-~0)-----------------------------------------------------
---------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, ANA ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE: 11-07-2011
ESTATE OF:POLLAK JEFFREY D DATE OF DEATH:O1-03-2011
COUNTY:CUMBERLAND
FILE NO.: 21 11-0779 S.S/D.C. NO.: 087-36-4142
ACN: 11139217
TAX RETURN WIAS: CX) ACCEPTED AS FILED C ) CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: WELLS FARGO
ACCOUNT NO.: 1010199086555
TYPE OF ACCOUNT: C )SAVINGS CX) CHECKING C )TRUST C )TIME CERTIFICATE
DATE ESTABLISHED 03-03-2008
Account Balance 15,773.00 NOTE: TO ENSURE PROPER CREDIT TO
Percent Taxable X 0.166
Amount Subject to Tax YOUR ACCOUNT, SUBMIT THE
2,628.89 UPPER PORTION OF THIS NOTICE
Debts and Deductions •00 WITH YOUR TAX PAYMENT TO THE
Taxable Amount 2,628.89
Tax Rate REGISTER OF WILLS AT THE
~ 12 ABOVE ADDRESS. MAKE CHECK
Tax Due 315.47
OR MONEY ORDER PAYABLE T0:
TAX CREDITS: "REGISTER OF WILLS, AGENT."
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
07-12-2011 CD014705 .00
394.33
TOTAL TAX PAYMENT 394.33
BALANCE OF TAX DUE 78.86CR
INTEREST AND PEN. .00
TOTAL DUE 78.86CR
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ;rt
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.