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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIYISION
PO BOX 280601
HARRISBURG PA 17128-0601
INHERITANCE TAX
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DOUGLAS CALAMAN
709 WEST PINE STREET
MT HOLLY SPRINGS PA 17065
Pennsylvania ~~~~
DEPARTMENT OF REVENUE
REV-1604 EX AFP (12-1ll ~---
DATE 04-05-2012
ESTATE OF CALAMAN LENA L
DATE OF DEATH 06-04-2011
FILE NUMBER 21 11-0829
COUNTY CUMBERLAND
SSN/DC 202-20-4328
ACN 11142544
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 F~
REV-1604 EX AFP C12-11)
*~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 04-05-2012
EST,4TE OF: CALAMAN LENA L DATE OF DEATH: 06-04-2011 COUNTY: CUMBERLAND
FIL1= NO.: 21 11-0829 S.S/D.C. N0.:202-20-4328 ACN: 11142544
ADJiUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINIANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 1 73864-1 1
TYP1= OF ACCOUNT: C ) SAVINGS (X) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE= ESTABLISHED 02-13-1998
Account Balance
Percent Taxable
Amount Subject to Tax
Debits and Deductions
Tax~;Ible Amount
Tax Rate
Tax Due
TAX CREDITS:
17,482.57
X 0.500
8,741.29
1,386.25
7,355.04
X .045
330.98
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 DF WILLS, AGENT."
P/1YMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) gMOUNT PAID
08-24-2011 CD014882 16.55 314.43
a
TOTAL TAX PAYMENT 330.98
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
"C12EDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE DF THIS FORM FOR INSTRUCTIONS.
REVJy70 EX f ~-10)
~ pennsylvania
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
_HARRISBURG PA 17128-0601
DECEDEIJT'S NAME
Lena L Calaman
REVIEWED BY
Eunice Baker
ITEM
SCHEDULE NO.
INHERITANCE TAX
EXPLANATION
OF CHANGES
E NUMBER
2111-0829
N
11142544
EXPLANATION OF CHANGES
The deductions submitted have been applied to the above account.
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