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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
INHERITANCE TAX
~~.~1.`r"~;,~~-0~F1fiC~ 1fE D ADJUSTMENT
C"f- 1fELD OR TRUST ASSETS
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CAMILLE K HYDER
1711 LOCUST STREET
NEW CUMBERLAND PA 17070
Pennsylvania ~ ~~`'
DEPARTMENT OF REVENUE
REV-1604 EX AFP (12-11) -~
DATE 03-16-2012
ESTATE OF KAVASANSKY CARMELA R
DATE OF DEATH 03-24-2011
FILE NUMBER 21 11-0511
COUNTY CUMBERLAND
SSN/DC 129-18-4974
ACN 11123010
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-1604 EX AFP C12-11~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE• 03-16-2012
ESTATE OF: KAVASANSKY CARMELA R DATE OF DEATH: 03-24-2011 COUNTY: CUMBERLAND
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 235209-00
FILE NO.: 21 11-0511 S.S/D.C. N0.:129-18-4974 ACN: 11123010
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
TYPE OF ACCOUNT: CX) SAVINGS ( ) CHECKING C ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 09-09-2003
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.
11,191.29 NOTE:
X 0.500
5,595.65
8,199.18
00
X .045
.00
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
TO: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID C-) AMOUNT PAID
~~ ~~
INHERITANCE TAX ~' ~~z
RECORD ADJUSTMENT pennsylvan~a ~' ~ ''
JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES REV-1604 EX AFP (12-11)
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
DATE 03-16-2012
ESTATE OF KAVASANSKY CARMELA R
DATE OF DEATH 03-24-2011
FILE NUMBER 21 11-0511
COUNTY CUMBERLAND
SSN/DC 129-18-4974
CAMILLE K HYDER ACN 11123011
1711 LOCUST STREET Amount Remitted
NEW CUMBERLAND PA 17070 -- -
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~1 RETAIN LOWER PORTION FOR YOUR RECORDS t-~
REV-1604 EX AFP (12-11~
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS *~
DATE• 03-16-2012
ESTATE OF: KAVASANSKY CARMELA R DATE OF DEATH: 03-24-2011 COUNTY: CUMBERLAND
FILE NO.: 21 11-0511 S.S/D.C. N0.:129-18-4974
ACN: 11123011
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1sT FCU ACCOUNT NO.: 235209-11
TYPE OF ACCOUNT: C ) SAVINGS (X) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 09-09-2003
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
628.82
X 0.500
314.41
628.82
.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."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) AMOUNT PAID
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.
/ •REV-1470 EX (01-10)
•
~ pe1111S~/ Va111a INHERITANCE TAX
DEPARTMENT OF REVENUE EXPLANATION
BUREAU OF INDIVIDUAL TAXES OF CHANGES
PO Box 280601
7
DECEDENT'S NAME FILE NUMBER
CARMELA R KAVASANSKY 2111-0511
REVIEWED BY ACN
Judy Watts 11123010 8~ 11123011
ITEM
SCHEDULE Np, EXPLANATION OF CHANGES
The deductions have been applied to the above ACN's leaving a zero balance due.
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