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''" INHERITANCE TAX
RECORD ADJUSTMENT pennsy~_
{~(~ ~f ~j(~~j HELD OR TRUST ASSETS
BUREAU OF INDIVIDUAL TAXES •^~'~~! ~/~ ~/1 (-I~j~~ DEPARTMENT OF :_
INHERITANCE TAX DIVISION p r~ ( , 1~^, ,^y- ~R~ ~
PO BOX 280601 R~+..~iv;"'k ~~;~ rl~i~~,l REV-1604 EX AFP (,
HARRISBURG PA 17128-0601
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AMY E DAVIES~M~R~D CA.,
2039 HARVEST DR
MECHANICSBURG PA 17055-7036
CUT ALONG THIS LINE ---! RETAIN LOWER PORTION FOR YOUR RECORDS E'-~
REV -16 0 4 EX AFP (12 -11) - ------------------------------------------------------------------------------------------------------
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE: 09-18-2012
ESTATE OF: DAVIES EDRIS W DATE OF DEATH: 03-26-2011 COUNTY:
CUMBERLAND
FILE NO.: 21 11-0544 S.S/D.C. N0.:
ADJUSTMENT BASED ON: ACN: 11130161
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: SOVEREIGN BANK
ACCOUNT NO.: 1685549204
2~i2 SEP 24 PN i~ 3S.
DATE 09-18-2012
ESTATE OF DAVIES EDRIS
DATE OF DEATH 03-26-2011
FILE NUMBER 21 11-0544
COUNTY CUMBERLAND
SSN/DC 193-24-1978
ACN 11130161
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING CX) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 11-02-2009
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
2,081.24
X 1.000
2,081.24
- .00
2,081.24
X .045
93.66
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 OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID C-)
04-23-2012 CD015879 .81-
09-17-2012 SBADJUST .00
AMOUNT PAID
94.47
.10
TOTAL TAX PAYMENT _ q3.6
BALANCE OF TAX DUE
--_0
INTEREST AND PEN.
.0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.AIIF DTO7AL DUE IS REFLECTED AS A
"CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
REV-7470 EX (01-10)
~' Pennsylvania
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280801
f oc~...... ._ _
SCHEDULE I ITEM
NO.
Edris W Davies
Robin Graff
INHERITANCE TAX
EXPLANATION
OF CHANGES
EXPLANATION OF CHANGES
2111-0544
11130161
Changed tax rate from 15 percent to 4.5 percent since a
beneficiary.
grandchild is a lineal
ROW
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