HomeMy WebLinkAbout06-01-12• ~~-+ ~ ;n ERITANCE TAX
BUREAU OF INDIVIDUAL TAXES ~~~'~''-~ ~"~~ ORD ADJUSTMENT
INHERITANCE TAX DIVISION pC//`~I.''i ~` ~~
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HARRISBURG PA 17128-0601
~~12 JUN - I PM 12~ 47
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DOUGLAS E GRIMES ~ ~"~
934 N LA JOLLA AVE
LOS ANGELES CA 90046-0000
Pennsylvania " ~~'
DEPARTMENT OF REVENUE
REV-1604A EX AFP (12-11)
DATE 05-25-2012
ESTATE OF GRIMES DIANE
DATE OF DEATH 04-21-2011
FILE NUMBER 21 11-0601
COUNTY CUMBERLAND
SSN/DC
ACN 11501236
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SgUARE
CARLISLE PA 17013
M
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS (--~
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REV-1604A EX AFP C12-11)
** INHERITANCE TAX RECORD ADJUSTMENT BENEFICIARY FORM ASSETS **
DATE: 05-25-2012
ESTATE OF: GRIMES DIANE M DATE OF DEATH: 04-21-2011 COUNTY: CUMBERLAND
FILE NO.: 21 11-0601 S.S/D.C. NO.: ACN: 11501236
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: AMERIPRISE
TYPE OF ACCOUNT: C~ SECURITIES C ) SEC ACCT ( ) STOCK
DOD Valuation
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Due
Tax Rate
TAX CREDITS:
.00 NOTE:
X 0.333
.00
.00
.00
X .045
.00
ACCOUNT NO.: 179818919
C ) BOND
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 (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE
INTEREST AND PEN. .00
TOTAL DUE .00
~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS
A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.