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HomeMy WebLinkAbout07-23-12 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 1]128-0681 JAMES R LEE 411 FLATWODD DR WINTER SPGS CU7 ALONG THIS LINE ft INHERITANCE TAX ~.~'~ru,C~ f`,CCd`GI{'~CORD ADJUSTMENT SOIN#i w HELD DR TRUST ASSETS RE(;,~,i~~,.; ; j~ ~,~n~ ~ S pennsylvania ~ DEPARTMENT OF REVENUE REV-1604 EX AFP I12-11) i'012 JUL 23 F!~ I ~ 25 DATE 07-10-2012 ESTATE OF LEE GUST R ~(~j :, :r DATE OF DEATH 08-05-2010 ~RPNAN~S C~U~T FILE NUMBER 21 10-0872 ~~~~~ ,~ PA COUNTY CUMBERLAND SSN/DC 172-18-1751 ACN :L1110548 Amount Remitted FL 32708 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER Of= WILLS 1 COURTHOUSE SpUARE CARLISLE PA 17013 ~- RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1604 EX AFP C12-11) ^* INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS 7e >E DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-2010 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.: 172-18-1751 ACN: 11110548 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.: 1695540573 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING C ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 10-05-2005 Account Balance Percent Taxable Amount Sub]ect to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: .00 NOTE: X 1.000 .00 .00 x .15 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 (-) ~ ANOUNT PAID TOTAL TAX PAYMEN7 .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" CCR7, YOU MAY eE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. , INHERI ^ (~(~ nr('~,^~{-' jf~~Q'~D TANCE TAX enns lvania ~ ADJUSTMENT f'{ ~CO °D~,I~M ~L17F~ WE}-D OR TRUST ASSETS DEPARTMENT OF REVEN UE BUREAU OF INDIVIDUAL TAXES (] (~ II~U}~~'~~ `C ~i~~~e ' REV-16D4 EX AFP a2-ill INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 11128-0601 20l2JUL23 PhR l~2~ DarE o7-lD-zDlz ESTATE OF LEE GUST R Vl -N~~~;,-.+U{- DATE OF DEATH OS-05-2010 _ ORPFiAPi'S Cia~~Ytr FILE NUMBER 21 10-0872 PA CtR~BERIAND Ct7 COUNTY CUMBERLAND ., SSN/DC 172-18-1751 JAMES R LEE ACN 11110550 411 FLATWOOD DR mount Remitted WINTER SPGS FL 32708 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 REC'.O RDS ~--' REV-1604 EX AFP C12-11) *~ INHERITANCE 7AX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS *~ DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-20].0 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110550 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.: 1695540615 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 11-04-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: 00 X 1.000 .00 .00 .00 X .15 .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT T0. THE REGISTER OF WILLS AT THE ADDRESS SHOWN ABOVE. MAKE CNECK OR MONEY DRDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT INTEREST/PEN (+) PAID (-) pMDUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE ,DO INTEREST AND PEN. .00 TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FDR CALCULATION OF ADDITIONAL INTEREST. IF TDTAL DUE IS REFLECTED AS A "CREDIT" (CR7, YOU MAV BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 JAMES R LEE 411 FLATWOOD DR WINTER SPGS CUT ALONG THIS LINE REV-1604 EX AFP 112-11) ~T~IC ,~gINHERITANCE TAX AFCU!~~d~~D ORJ TRUST ASSETS Pennsylvania ~ DEPARTMENT OF REVENUE REV-1604 EX AFP Q2-lll 2012 JUL 23 PN ~° 29 DATE o7-to-zDlz ESTATE OF LEE GUST R ~.~ ~t1„~ (~IC DATE OF DEATH 08-05-2010 ORPHANS COURT COUNTVUMBER CUMBERLAND (;VAhBERt.ANDCO..PA SSN/DC 172-18-1751 ACN 11110552 mount Remitted FL 32708 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 ~-- RETAIN LOWER PORTION FOR YOUR RECORDS ~ ^^ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD DR TRUST ASSETS x+c DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-201.0 COUNTY: CUMBERLAND FLLE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110552 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: soVEREIGN BANK ACCOUNT NO.: 1695541316 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST CX) TIME CERTIFICATE DATE ESTABLISHED 09-05-2006 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: .00 X L.000 .00 .00 .00 X .15 .00 NOTE: TO ENSURE PROPER GR~DIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE RESISTER OF WILLS AT THE ADDRESS SHOWN ABOVE. MAKE CHECK OR MONEY ORDER PAYABLE 70: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT I+) INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF 7AX DUE .00 INTEREST AND PEN. .00 TOTAL DUE IF PAID AFTER THIS DATE. SEE REVERSE FDR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL OUE IS REFLECTED AS A "CREDIT" ICR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR IN1iTRUCTI0N5. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 2806D1 HARRISBURG PA 1]128-0601 JAMES R LEE 411 FLATWDOD DR WINTER SPGS CUT ALON6 THIS LINE REV-1604 EX AFP (12-11) INHERITANCE TAX rye ORD ADJUSTMENT Pennsylvania ~ ~~J[~I~~1~IELD OR TRUST ASSETS DEPARTMENT OFREVENUE RED-l5~c~ ~ 1~; {TLS REV-1604 EX AFP (12-llJ 2U12JUL 23 PM i~ 29 DATE 07-10-2012 ESTATE OF LEE GUST R DATE OF DEATH 08-05-2010 ~,Lt'.~~ "~ FILE NUMBER 21 10-0872 ORPHANSIiOURt COUNTY CUMBERLAND ~~{'3~p (~,Q„ ~ SSN/DC 172-18-1751 ACN 11110554 mount Remitted FL 32708 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHO U:SE SQUARE CARLISLE PA 17013 ~ RETAIN LOWER PORTION FOR YOUR RECORDS !~ ~x INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~^ DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-2010 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110554 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.: 1695540516 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING C ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 09-01-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: .00 NOTE: X I.BOD .00 .O9 15 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 C+) PAID (-) AMOUNT PA1~ TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. ,00 TOTAL DUE IF PAID AFTER TNIS DATE. SEE REVERSE FDR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL OVE IS REFLECTED AS A "CREDIT" (CR), YOU MAV BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. INHERITANCE TAX CORD ADJUSTMENT Pennsylvania ~ Nf~~R1.t('~J ~~ HELD OR TRUST ASSETS DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES (~[(~t- (f"r ~ ~~(~ ~ REV-1604 E%AFP cl2-li) INHERITANCE TA% DIVISION Il[,12~V~Lr! l~~ ~•1-4'~ PD BD% 280601 lUIRRISBURG PA 17128-0601 20I2JUL23 PM 129 DATE 07-10-2012 ESTATE OF LEE GUST R DATE OF DEATH 08-05-2010 "~!-~"" `-'' FILE NUMBER 21 10-0872 npp ~Iri wY~S vQURT COUNTY CUMBERLAND ~~~p ~" ~ SSN/DC 172-18-1751 JAMES R LEE ACN 11110543 411 FLATWOOD DR mount Remittetl WINTER SPGS FL 32708 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS L COURTHO U.S"E SQUARE CARLISLE NA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS F REV-1604 EX AFP (12-11) ^~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ^^ DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-2010 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110543 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SoyEREiGN BANK ACCOUNT N0.: 1695540326 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 07-13-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due .00 N07E: 1.000 .00 .00 X .15 .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 T0: ^REGISTER OF WILLS, AGENT.•' TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) ~ AMOUNT PA I~ TOTAL TAX PAYMENT .p0 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ]:F TOTAL DUE IS REFLECTED AS A •'CREDIT•• (CR), VOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. INHERITANCE TAX RE RD ADJUSTMENT p@nnsylvania ~ Q[.(~~f:~0-LAY LD OR TRDST ASSETS DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES 1•' v~ ..~ "~~~V/+- REV-1604 EX AFP (12-1ll INHERITANCE iAX DIVISION ~~1.~!S~C.ti ~~~ ~Y~~y~~ PO BOX 280601 HARRISBURG PA 17128.0601 2Q12JUL23 PM 130 DATE 07-LO-2012 ESTATE OF LEE GUST R DATE OF DEATH 08-05-2010 vLC(~d`. ..,. FILE NUMBER 21 10-0872 Q(~P~-~~'~ (;Q()RT COUNTY CUMBERLAND JAMES R LEE ~~~LANQ ~•'~ SSN/DC 172-18-1751 ACN 11110544 411 FLATWOOD DR WINTER SPGS FL 32708 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SpUARE 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 TRUST ASSETS ~r DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: D8-05-20].0 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110544 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.;1695540383 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 08-01-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: .00 X 1.000 .00 .00 .00 X .15 .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 TO: "REGISTER OF WILLS, AGEN T.^ PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT P,4I TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. 0 TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR)r YOU MAV BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS. +/ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 JAMES R LEE 411 FLATWOOD DR WINTER SPGS CUT ALONG THIS LINE INHERITANCE TAX (1C'lV1DIlCF'1 nCClf!4Q11~RD ADJUSTMENT ELD OR TRUST ASSETS ~I[ '. T f Pennsylvania ~ DEPARTMENT OF REVENUE REV-1604 EX AFP (12-11) Oi2JiJL23 PM 130 r' . DATE D7-to-zDlz ESTATE OF LEE GUST R r . DATE OF DEATH 08-05-2010 , vi_4 r,~ OR~~S LU~RT FILE NUMBER 21 10-0872 ~ a~~RL~~ ~ COUNTY CUMBERLAND -' SSN/DC 172-18-1751 ACN 11110545 maunt Remitted FL 32708 ~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE I'A 17013 ~- RETAIN LOWER PORTION FOR YOUR RECORDS (~ REV-1604 EX AFP C12-11) ^~ INHERI7ANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS Itx DATE: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-D5-2010 COUNTY: CUMBERLAND FILE NO.: 21 10-0872 S.S/D.C. N0.:172-18-1751 ACN: 11110545 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.: 1695540508 TYPE OF ACCOUNT: C ) SAVINGS ( ) CHECKING C ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 09-OL-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: .DO X L.000 .00 .00 .00 X .15 .00 NOTE: TD ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR 7AX PAYMENT TO THE REGISTER OF WILLS AT THE ADDRESS SHOWN ABOVE. MAKE CHECK OR MONEY ORDER PAYABLE TD: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID (-) AMOUNT PAI~ 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 TOTpL OUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR IN<-~TRUCTIONS. ' ' INHERI D TANCE TAX Q1111S lvania ~ JUSTMENT P Y ~C~'~rn'~~OR Q Cllr ELD AD OR TRUST ASSET$ DEPARTMENT OF REVEN UE BUREAU OF INDIVIDUAL TAXES [~,(` f t-lr' ~~~1Q ti R S U REV-1604 E% AFP (12-11) INHERITANCE TAX OIV IS ION l 1 I ~i7 ~ a t L + PO BO% 280601 HARRISBURG PA 1T128-0601 2U12 JUL 23 PM I ~ 30 DATE 07-10-2012 ESTATE OF LEE GUST R DATE OF DEATN OB-05-2010 '~7-~~~~% FILE NUMBER 21 10-0872 ORPHANS ~QURT COUNTY CUMBERLAND Iy V~R~(~ ~., ~ SSN/DC 172- 18- 1751 JAMES R LEE ACN 11110547 411 FLATWOOD DR mount Remitted WINTER SPGS FL 32708 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SgUARE CARLISLE PA 17013 CU7 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: 07-10-2012 ESTATE OF: LEE GUST R DATE OF DEATH: 08-05-207.0 COUNTY: CUMBERLAND FILE NO.: 21 LO-0872 S.S/D.C. N0.: 172-18-1751 ACN: 11110547 ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT N0.: 1695540565 TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE DATE ESTABLISHED 10-05-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAY CRFDTTSe .00 X 1.000 .00 .00 .00 X .15 .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TD THE RE6ISi ER OF WILLS AT THE ADDRESS SHOWN ABOVE. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, A6EN T." PAYMENT DATE RECEIPT NUMBER DISCOUNT INTEREST/PEN (+) PAID (-) pM DU NT F'A ID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE 0 INTEREST ANO PEN. 0 TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAV BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.