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BUREAU HINDI YII DUAL TAXES ~['V~,{i~; L;
INHERITANCE TAX DIVISION (-~~~~~^; it-r
PO BOX 280601 ~~_CiN ~;-'
HARRISBURG PA 1]128-0601
INHERITANCE TAX
N,I RECORD ADJUSTMENT
U~~II~CI,.~r.H.ELO OR TRUST ASSETS
r,~- leq~ ,f
.a d4'.-~..J
CLERK GF
ORFHr~N'S COURT
KAREN REIGLECU~VAh.kL/"~s~In ~",.~;~.~ Fie.
4614 SPRING ROAD
SHERMANS DALE PA 17090
Pennsylvania ~
DEPARTMENT OF REVEN UE
REV-1604 EX AFP (12-1ll
DATE 02-28-2012
ESTATE OF SHERICK EDITH F
DATE OF DEATH 11-18-2010
FILE NUMBER 21 11-0900
COUNTY CUMBERLAND
SSN/DC 180-18-8686
ACN 11119031
Ameunk Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV-1604 EX AFP (12-11)
^~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRIJST ASSETS ~^
DATE: 02-28-2012
ESTATE OF: SHERICK EDITH F DATE OF DEATH: 11-18-2010 COUNTY: CUMBERLAND
FILE NO.: 21 11-0900 S.S/D.C. N0.: 180-18-8686 ACN: 11119031
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: WACHOVIA BK NA ACCOUNT N0.: 1010009674332
TYPE OF ACCOUNT: ( ) SAVINGS (X) CHECKING ( ) TRUST C ) TIME_ CERTIFICATE
DATE ESTABLISHED 02-20-2002
Account Balance
Percent Taxable
Amount Subaect to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00 NOTE:
X 0.500
.00
.00
.00
X .15
.00
TO ENSURE PROPER CREDIT TO YOUR
ACCOUNT-, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMEN I- 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
INTEREST/PEN (+)
PAID
(-) gMDU NT PiCID
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" (L R). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~~
Rev-uio ex ~ovio~
p~nr~sylvania
DEPARTMENT OF REVENUE
BUREAU OF INDNIDUAL TAXES
PO Box 280801
Edith F. Sherick
James Russell
INHERITANCE TAX
EXPLANATION
OF CHANGES
2111-0900
11119031
ITEM
SCHEDULE NO, EXPLANATION OF CHANGES
Above-referenced ACN(s) are being adjusted to reflect zero tax due since they have been
reported on the probate return.
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