The URL can be used to link to this page

Home My WebLink About02-23-12 J 1505610105 REVI-1500 IX (oz-u) (FI) ~` OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Count Code Year File Number Bureau pf Individual Taxes DFG4'iNfXT Of IIEVEMUF Y PO Box z8o6oi INHERITANCE TAX RETURN HarrisbUro,PA17tz8-o6oi RESIDENT DECEDENT ZI ~~ OG~BS ENTER DECEDENT INFCCjRMATION BELOW Social ;iecurity Number Date of Death MMDDYYYY Date of Birth IdMDDYYYY l ~ to l '~ 13757 0/ /.~z,Zo/I o7/z/~tSZ ~ Decede:nt's Last Name Suffix Decedent's First Name MI aE~i~ D t ~ ~~ ~- (If Appliicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Mumber THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE Cf VALS BELOW O 1. Original Retum f• 2. Supplemental Return O 3. Remainder Retum (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decedent Daed Te~~~ate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Vt~ill) (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 Schedule O) CORRESPONDENT - THIS SE TION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Sil.~.~ a L3'l t^V A~ N s 7 t T- 7b~ - 73 2!0 First line of Address 2 ~ N F;~~~9 ~ Ca c~c.~t-r- Second Line of Address City or Fost Office State ZIP Code ,.,.a REGISTER ~'~IrILL3 USE O rv -~-} ~'C] rt T C-7 i-rt c,~a Jy ~ F t -\) '~~ U7 ~ Cw7 p ~~ C a] D FILiED t /12E'c~~~~c~ ~~-~G ~R 1 70 ~_ o ~, Correspondent's a-mail address: _ ~ ~ C~ aTMC ~ ~ OL. ~ O rf? ~7 -T'.t ;-'~'1 r:IC'' t ,"a ~~: .ZJ r.~ r_~ _r.~ ~`": -.~ tTt `~ ~ '-rl Under penalties of perjury, 1 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 RSON R P. N FOR FILING RETURN DATE 2 Z! ADDRESS SIGNATURE OF PREPARER THER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056'10105 15D5610105 J 1505610205 REV-15p0 EX (FI) d ~fi J ~ ,QEA ~D Decedent's Soci al Security Number Decedent's Name' ', ~ / ~ . 7 G"l T ~s 7 ~'f 7 RECAPITULATION 1. Real Estate (Sch~ dule A) .......................................... ... 1. ~~.+ / ~ OC.~ t~O ' 1 2. Stocks and Bond~ (Schedule B) .................................... ... 2. 3. Closely Held Cor oration, Partnership or Sole-Proprietorship (Schedule C) .. ..., 3. 4. Mortgages and N tes Receivable (Schedule D) ........................ ... 4. 5. Cash, Bank Depo its and Miscellaneous Personal Property (Schedule E).... ... 5. ', 6. Jointly Owned Pr perty (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transf rs & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Ass is (total Lines 1 through 7) ........................... .. 8. 2 S 7 5ba. O O 9. Funeral Expense and Administrative Costs (Schedule H) ................. .. 9. j y, 7.~ 3•'~ 10. Debts of Deceden ,Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 11. Total Deductions (total Lines 9 and 10) ............................... .. 1L ' 3~ ?.~ 3• .~4~ ~ _ _ 12. Net Value of Es to (Line 8 minus Line 11) ............................ .. 12. 13. Charitable and Go vernmental Bequests/Sec 9113 Trusts for which an election to tax as not been made (Schedule J) ...................... .. 13. 14. Net Value Subjec ~ to Tax (Line 12 minus Line 13) ...................... .. 14. ~ Z Z~ 7 ~ ~ • ~ ~o TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under S c. 9116 - (a)(1.2) X .0- ' 15. 16. Amount of Line 14 taxable at lineal rate X .0 16 ~~ Q~ ~}~ I ~o 17. Amount of Line 14 taxable at sibling rate X .1 2 17 18. Amount of Line 14 taxable at collateral rate 15 18 19. TAX DUE ....... .............................................. .... 19. ' 1d 0.x.4. C"Jb 20. FILL IN THE F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610205 1505610205 O REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Ed,~ti 'T. ~3c,ar d ~_ _ STREET ADDRESS / wit ~e,ue~ ~i s 1,, ,c e: S q ~.~.~4 ,t e ------------------ -- ---- CITY EGl~A --------------------- tcS r3 v,2G STATE-------- ~~- ZIP t ?p ~ ° Tax Payments and 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ B. Discount. its: /D O.Z ~f .4 C. Total Credits (A + B) (2) 3. Interest I 4. If Line 2 is greater than Line 1 ~ Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 2 to request a refund. (4) 5. If Line 1 + Line 3 is greater tha Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. ~o o ~ ~. y~ /ooh ~ 4~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent ake a transfer and: Yes No a. retain the se or income of the property transferred .................................................................................... ...... ^ b. retain the r ght to designate who shall use the property transferred or its income ...................................... ...... ^ Q c. retain a re rsionary interest ........................................................................................................................ ...... ^ d. receive the promise for life of either payments, benefits or care? ............................ 2. If death occur d after Dec. 12, 1982, did decedent transfer property within one year of death without receivi g adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent wn an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 4. Did decedent wn an individual retirement account, annuity or other non-probate property, which contains a ben eficiary designation? .................................................................................................................. ...... ® ^ IF THE ANSWER TO ANY OF TIE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after Juty , 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)J. For dates of death on or after Ja . 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 st tute 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 applicabl even if the surviving spouse is the only beneficiary. For dates of death on or after July , 2000: • The tax rate imposed on the n t 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 stepparen of the child is 0 percent [72 P.S. §9116(a)(1.2)J. • The tax rate imposed on the net slue 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(a)(1)]. • The tax rate imposed on the n t value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an indi idual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+'(6-98) , SCHEDULE A COMMONWEALTH OF PENNSYLVi~1NIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~d,fhT. ~e~-~d ~~ rr -a r8s All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing uyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real p operty which is jointly-owned wlth right of gurvivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~cl raA~t eVOn~'~t~C S4 S'oo• 00 '+I ~ 57 ~« {~ ~~~ ~~ ~~~ ~~ ~~ ~~ ~I I~ s ~ of ~ ~ 1 ~ o sd ~ n « 5 ~ TOTAL (Also enter on line 1, Recapitulation) $ s~s7 500. c.o (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06J~ SCI~IEDI~ILE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURIU ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSE 1. ~I I B. ~~ ~i ADMINISTRATIVE CO TS: 1. Personal Representati 's Commissions Name of Person I Representatives} Street Address i City State Zip Year(s) Commis ion Paid: 2. Attorney Fees 3. Family Exemption: (If d cedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip _ Relationship of laimant to Decedent 4• Probate Fees 5. Accountant's Fees ~ 6. Tax Retum Preparer's ees ~. ses E)c~tn ,[~, la.~-e~ ~ Mtgr,n'E1htn~.~5 ~rv~otr ~7 ~t ~0 38 ~. `f'8 LL a-T I ~ JG~6nS~~LC 5~t,.~wv~G L ~ a#t ~~~ $, ~cloa~.~,~ 5 r c ~r ~~ {~ s c LL ~ r d~ c ~ ~ (,ok ~c..cka.d) ~ ~- ? /. G 7 cl. ,~~{~ltw~cn. c.os lS ~So~z. og TOTAL (Also enter on line 9, Recapitulation) $ 3 ~ 7 ~ 3 ~ j (If more space is needed, insert additional sheets of the same size) ~d ~f'I~ ~" ~ ~~ r d. apt' ~ -o yes x ~~n s CI S rt ~w~d to ra e,e.-- ~,-f---Y_._.~_.__._..~___ _ ____~_.. ___.____.__._~---- ~1___~Cv _ R__S ~ ~ rc _-- S~k ~ rc.c. ---.----------___-_________-------- -_ __. __--- ___.__._ ___ _.__.____.__ cal Esta~~k. f~.~c~s ~ d ~- 3 0 -, t ~ ~i7. 1'f ______ _._._._._._-- c~..l ~s~.l~c~~ .__~ _ ~m~ oty/t~r s t -~ s u~,.rc~.n c e - t 12 t E ~i~ 5 __ -- _.___.- - __ _ _ --- ------ -- r_ ~_ vons~-~ ra SQ~+-arc Lon ~orK~,~, tsJ m }BLS _ .-- _ __-.____ _____.__ _. -- __ 4µ_QT.!?- ~R~e.~,~e.e~o_n _~ A Stir 'C _ ~_~ . l ILITI E5 ------_ __ _ _ _ . - _ _ . ____-_- . -._-_._._____ _ ___._.____ ... ~ . -- _ _ _ _ ____~_.___ __ ____ _ ~~ee~r~c~ ~ ~/7. 37 ~I ---------._____ ~__~.____ _ _._. __._...._.__1 ~ 1~15~+ ~ ~G .w~~lT~-as 1t 3 T,~S --_~_~.~'r-~--~ ~~ - ---- .. _ _. _ _._._.__. _ .. __.___ ~ ~.__~_~_-~ ~ b `f. t~ GU ____ ______ ___.__._~w__~ _ ~- _.__._-___. I ----------._~.__ -----j --- -- -- -- - - t d ~t-~ 7. ~ ~~ ~ d -- --_ - 8 .__.e_ __ __ --. --.~_L _ ~-~__„~ . /3 / l • ~ i~w. _A aril- orbs I / 7d'. v d~ ~ ate, . _ ---- ~~ ~, ----- ------ - _+----------- 1 ____-. -______ _..,~______ ___.._._. a '~ ~ G 7/, G 7 ___ __ _, _ ---N___._~..-____.__ _. ___ _._ ~.___.~._ _._I I __~. -~------ - - - j . r .~_ _.. --^Y~--~~..~.__---- -------------- ------ i I - -- __ REV4b0 EX (0~-70) ` - ~ pennsylv~ania INHERITANCE TAX DEPARTMENT OF REVENUE EXPLANATION BUREAU OF INDIVIDUAL TAXES OF CHANGES Po ~ zsoeo~ DECEDENT'S NAME Edith .~ Beard REVIEWED BY Yvonn Bricker R 2111-0185 fQ1 SCHEDULE I INO EXPLANATION OF CHANGES A 1 Accep~ed revised return. H-B 7,8,9 Accep~ed revised return. FILE Paae 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: EVANS SUSAN B 204 FRIAR COURT MECHANICSBURG, P. fold PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT 17050 ESTATE INFORMATION: ssN: iss-i4-3797 FILE NUMBER: 21 1 1-0185 DECEDENT NAME: B ARD EDITH J DATE OF PAYMENT: 1 /14/2011 POSTMARK DATE: 1 / 14/201 1 COUNTY: C MBERLAND DATE OF DEATH: 01 /22/201 1 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~ 53,038.16 TOTAL AMOUNT PAID: REMARKS: CHECK#1025 SEAL INITIALS: HEA RECEIVED BY: 53,038.16 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EXI11-961 NO. CD 015064 TAXPAYER __ __ r QF EDITH...) BEARD ~~61os 1~~4'Q N B EVANS, E~CEC 3A B CORR~E,EXEC DATEV _` /7 2011 PAY TO THE ORDER OF ~ ~.P,., iruo w» l ~lrl ~dliK i, Hampdwi OIR MEMO x:03 i3 2955: r~ ~ y~~ pp_ DOLLARS LJ ~,, 98 5 380 7_L 9 7~i` i0 40 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVEPJUE BUREAU OF INDIVIDUAL. TAXES DEPT. 280601 HARRISBURG, PA 171 28-0601 3ECEIVED FROM: EVANS SUSAN B 204 FRIAR COURT MECHANICSBURG, PA REV-1162 EX111-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT 17050 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold ESTATE INFORMATION: ~ ssN: 196-~4-3797 FILE NUMBER: 21 1 1 -01 85 DECEDENT NAME: BE RD EDITH J DATE OF PAYMENT: 1 1 / 1 7/201 1 POSTMARK DATE: 1 1 / 1 7/201 1 couNTY: CU BERLAND DATE OF DEATH; 01 22/2011 101 ~ 510,024.96 NO. CD 015219 TOTAL AMOUNT PAID: REMARKS: SUSAN EVAIf SEAL CHECK#1040 JS INITIALS: WZ RECEIVED BY: 510,024.96 GLENDA EARNER STRASBAUGH REGISTER OF~ WILLS TAXPAYER __ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: REV-1162 EX111-961 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT EVANS SUSAN B j 204 FRIAR COURT '~ MECHANICSBURG, P~ 17050 N0. CD 015285 ACN ASSESSMENT AMOUNT CONTROL NUMBER ESTATE INFORMATION: ' ssN: 1ss-i4-3797 FILE NUMBER: 21 1 1-0185 DECEDENT NAME: BE ARD EDITH ~ DATE OF PAYMENT: 1 ? /05/201 1 POSTMARK DATE: 1 /02/201 1 COUNTY: C MBERLAND DATE OF DEATH: 01 /22/201 1 101 ~ 521.36 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK# 3979 521.36 INITIALS: DMB RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER BUREAU DF INDIVIDUAL TAXES INHERITANCE TAX OfVISION PO BOX 200601 HARRISBURG PA 17120-0601 ', SUSAN B EVANS 204 FRIAR CT MECHANICSBURG NOTICE OF INHERITANCE TAX Pennsylvania ~ APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE OF DEDUCTIDNS AND ASSESSMENT OF TAX REV •1547 EX AFP ciz-l0) DATE 11-28-2011 ESTATE OF BEARD EDITH J DATE OF DEATH 01-22-2011 FILE NUMBER 21 11-0185 COUNTY CUMBERLAND ACN 101 APPEAL DATE: Oi-27-2012 P A 17 0 5 D (See reverse side under Objections ) Aaount Reaitted~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALON_C THIS _LINE_ _ ~ R_ETAIN LOWER POR_TIDN_ FOR YOUR RECORDS !~ _ _______________ REV-1547 EX AFP C12 10) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS°-AND ASSESSMENT OF TAX ESTATE OF: BEARD EDITH JFILE N0.:21 11-0185 ACN: 101 DATE: 11-28-2011 TAX RETURN YIAS: ( ) ACCEPTED AS FILED C X) CHANGED $EE ATTACHED NOTICE APPRAISED VALUE OF ETURN BASED ON: ORIGINAL RETURN I. Real Estate CSeh dul• A) 2. Stocks and Bonds CSchodule B) S. Closely Held Sto k/Partnership Interest CSchodule C) 4. Mortgages/Notes acoivable CSehadulo D) 5. Cash/Hank Deposi s/Misc. Personal Property (Schedule E] 6. Jointly Owned Pr party (Schedule F) 7. Transfers CSchodule G7 E. Total Assets APPROVED DEDUCTIDNS AND EXEMPTIONS: 9. Funeral Expense /Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage iabilities/Liens CSehadulo I) C1)__ 257,500.00 NOTE: To ensure proper C2) 2, 624.03 credit to your account, .00 submit the upper vortion C37 of this form with your C4) •00 tax payment. cs) 22.172.42 c6) 32.758.00 IT) 23, 874.83 ca) c9) 48.637.92 Ile) • 00 C11) 48.637.92 11. Total Deduction 290.291.36 12. Net Value of Ta Return C12) 00 13. Charitable/Govo nmental Boquastsi Nan-slotted 9113 Trusts CSchodule J) C13) . T (14) 290.291.36 14. Net Value of Es ax ate Sub3ect to NOTE: If sn asses ^ent wars issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect fig res that include the total of ALL returns assessed to d ate. ASSESSMENT OF TAX: 00 00 = .DD 15. Amount of Lina 4 at Spousal rate C15) . X 16. Amount of Lino 4 taxable at Lineal/Class A rata (16) 9 d. 91_36 x 045 = 13,06 3.11 17. Amount of Line 4 at Sibling rate C17) . DD X 12 . 00 18. Amount of Lino 4 taxable at Collateral/Class H rate C18) .00 X 15 = .00 C14)= 13.063.11 19. Principal Tax D o TAX CREDITS: PAYMENT N ~tiri +++~~~~^' •~~ ANDUNT PAID PATE UMBER .INTEREST/PEN PAID C-) 10-14-2011 CD 15064 .00 3,D38.16 11-17-2011 CD 15219 .O1- 10,D24.96 BALANCE OF UNPALD NTEREST/PENALTY AS OF 11-18-2011 TDTAL TAX PAYMENT 13,063.11 6ALANCE OF TAX DUE .00 INTEREST AND PEN. 21.36 j TOTAL DUE 21.36 + IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR). YOU MAY BE DUE FOR CALCULATION OF ApD~EDITIDNAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXE$ INHERITANCE TAX DIVISION PO BOX 260601 HARRISBURG PA li'126-0601 SUSAN B EVANS 204 FRIAR CT MECHANICSBURG i INHERITANCE TAX STATEMENT OF ACCOUNT Pennsylvania ~~~~`~ DEPARTMENT OF REVENUE REV-1607 EX AFP (12-11) DATE 12-27-2011 ESTATE OF BEARD EDITH J DATE OF DEATH 01-22-2011 FILE NUMBER 2.1 11-0185 COUNTY CUMBERLAND ACN 101 Amount Remitted PA 17050-6872 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 _ _~_ _ __RE_TAIN LOWER PORTION FOR YOUR RECORDS _ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ REV-1607 EX AFP C12- 1) *** INHERITANCE TAX STATEMENT OF ACCOUNT *** ESTATE OF:BEARD EDITH J FILE NO.: 21 11-0185 ACN: 101 DATE: 12-27-2011 THIS STATEMENT PROVIDES C~RRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF A L PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSM NT OR RECORD ADJUSTMENT: 11-21-2011 PRINCIPAL TAX DUE: 13,063.11 PAYMENTS (TAX CREDIT ): PAYMENT RE EIPT DISCOUNT (+) AMOUNT PAID DATE NU BER INTEREST/PEN PAID (-) 10-14-2011 CD 015064 .00 3,038.16 11-17-2011 CD 015219 .O1- 10,024.96 12-02-2011 CD 015285 21.36- 21.36 TOTAL TAX PAYMENT 13,063.11 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE 00 * IF PAID AFTER THIS DA E, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLE TED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.