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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
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KERMIT M SHOUN (;R ~`?`i- - '.%a
331 RICH VALLEY RD
CARLISLE PA 17015
Pennsylvania°~: ~ _:.
DEPARTMENT OF REVENUE
REY-1604 EX AFP (12-11)
DATE le!-27-2011
ESTATE OF SHOUN KERMIT T
DATE OF DEATH 09-28-2010
FILE NUMBER 70 0424846 I ~~` 1~ ~'
COUNTY CUMBERLAND
SSN/DC 1'_i9-32-2735
ACN lO1b2486
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TD:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~1 RETAIN LOWER PORTION FOR YOUR REC _--~-
------------------------- 0 RD S --------°E-
REV-1604 EX AFP C12-~1)
~~ INHERITAN E TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 12-27-2011
ESTATE OF: SHOUN KERMIT T DATE OF DEATH: 09-28-2010 COUNTY: CUMBERLAND
FILE NO.: 70 042484!'
ADJUSTMENT BASED !C
S_S/D.C. N0.:159-32-2735
ACN: 10162486
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: FULTON BANK NA ACCOl1NT NO.: 025-0253693
TYPE OF ACCOUNT: { ) SAVINGS C ) CHECKING { ) TRUST {X) TIME CERTIFICATE
DATE ESTABLISHED 04-05-2007
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
PAYMENT I RNU~MB
DATE
.00
X 0.166
.00
.00
.00
X .045
.00
NOTE: TO ENSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE .ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
DISCOUNT (+) AMOUNT PAID
INTEREST/PEN PAID (-)
TOTAL TAX PAYMENT .I
BALANCE OF TAX DUE ,~
INTEREST AND PEN. ,i
TOTAL DUE
^ IF PAID AFTER THIS DAfiE, SEE REVERSE 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.
REV-147~~F.x~01-10)
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DEPARTMENT OF REVENUE
BUREAU OFINDIVIDUAITAXE$
PO Box 280801
HARRISBURG PA 17128-0601
DECEDENTS NAME KERMIT 'Ir SHOUN
REVIEWED BY Robin Gaff
INHERITANCE TAX
EXPLANATION
OF CHANGES
NUMBER
700424846
10162486
SCHEDULE INO EXPLANATION OF CHANGES
Signatur$ card provided showing named individual was nat a beneficiary of the account
under the above A C N.
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