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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX OIV ISION
PO BOX 280601
HARRISBURG PA 17128-0601
INHERITANCE 7AX
~,~ ~G CORD ADJUSTMENT
~f CUf'1~ {-j' ~N/fJ~ HELD OR TRUST ASSETS
C~2 AU~Z4 A~~~• J~
(~jO~RPNA~;'S ~OURi
GARY A WILLIEYt ~gERIAND CO., PA
610 WATEREDGE ROAD
L ITITZ PA 17543-8766
pennsylvania ~
DEPARTMENT OF REVENUE
REV-1604 EX AFP Q2-11J
DATE 08-21-2012
ESTATE OF WASSER PAULINE M
DATE OF DEATH 07-31-2011
FILE NUMBER 21 11-0929
COUNTY CUMBERLAND
SSN/DC 168-32-1344
ACN 11153581
Amount Remittetl
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FDR YOUR RECORDS H
REV-1604 EX AFP C12-11)
^~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ^^
DATE: 08-21-2012
ESTATE OF: WASSER PAULINE M DATE DF DEATH: 07-31-2011 COUNTY: CUMBERLAND
FILE NO.: 21 11-0929 S.S/D.C. N0.: 168-32-1344 ACN: 11153581
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: susguEHANNA BANK ACCOUNT N0.: 1102865909
TYPE OF ACCOUNT: ( ) SAVINGS IX) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 08-31-2006
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
10,762.19 NOTE:
X 0.166
1,793.73
.00
1,793.73
X .045
80.72
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, ADEN T.'•
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+7
INTEREST/PEN PAID (-7 AMOUNT PAID
INTEREST IS CHARGED THROUGH 09-05-2012 TOTAL TAX PAYMENT .00
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE BO
REVERSE SIDE OF THIS FORM INTEREST AND PEN. 85
70TAL DUE
~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF AODITIDNAL INTEREST. IF TOTAL DUE IS REFL ECTEO AS A
"CREDIT" (CR), VOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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