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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIYISION
PO BOX 280601
HARRISBURG PA 17128-0601
/~ (INHERITANCE TAX
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JEAN M UPDEGRAFF
1010 APPLE DR
MECHANICSBURG PA 17055-3409
Pennsylvania ~~ ~~~
DEPARTMENT OF REVENUE
REV-1604 EX AFP Q 2-11)
DATE 02-09-2012
ESTATE OF UPDEGRAFF ROBERT C
DATE OF DEATH 06-21-2010
FILE NUMBER 21 10-0712
COUNTY CUMBERLAND
SSN/DC 177-12-2136
ACN 11106727
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 ~
REV-1604 EX AFP C12-11~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE• 02-09-2012
ESTATE OF: UPDEGRAFF ROBERT C DATE OF DEATH: 06-21-2010 COUNTY: CUMBERLAND
FILE NO.: 21 10-0712 S.S/D.C. N0.:177-12-2136
ACN: 11106727
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: SOVEREIGN BANK
ACCOUNT NO.: 1681704803
TYPE OF ACCOUNT: C ) SAVINGS (X) CHECKING C ) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 03-02-1992
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A
"CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
14,838.18
X 0.500
7,419.09
.00
7,419.09
X .00
.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."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) AMOUNT PAID
P~
REV-1470~X (01-10)
~` INHERITANCE TAX
~ pennsylvania
DEPARTMENT OF REVENUE EXPLANATION
BUREAU OF INDIVIDUAL TAXES OF CHANGES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME FILE NUMBER
ROBERT C UPDEGRAFF 2110-0712
REVIEWED BY ACN
Robin Graff 11106727
SCHEDULE 'ND" EXPLANATION OF CHANGES
The value of the account subject to tax has been adjusted to zero since the account was
held by husband and wife as entireties property.
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