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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
INHERITANCE TAX
CORD ADJUSTMENT
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DAV I D E DAV I E~~MBERIAND CO•, PA
2039 HARVEST DR
MECHANICSBURG PA 17055-7036
Pennsylvania ~
DEPARTMENT OF REVENUE
REV-1604 EX AFP (12-11)
DATE 09-18-2012
ESTATE OF DAVIES EDRIS W
DATE OF DEATH 03-26-2011
FILE NUMBER 21 11-0544
COUNTY CUMBERLAND
SSN/DC
ACN 11130160
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE --1 RETAIN LOWER PORTION FOR YOUR RECORDS F-
REV-1604 EX AFP C12-11)
** 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.: ACN: 11130160
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: SOVEREIGN BANK ACCOUNT NO.: 1685549196
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING CX) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 11-02-2009
Account Balance
Percent Taxable
Amount Sub]ect to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
4,369.49 NOTE:
X 1.000
4,369.49
.00
4,369.49
X .045
196.63
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 C-) AMOUNT PAID
04-20-2012 CD015881 1.71- 198.34
09-17-2012 SBADJUST .00 .16
TOTAL TAX PAYMENT 196.63
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" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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REV-5470 EX (01-10)
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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
___ PO Box 280601
Edris W Davies
Robin Graff
SCHEDULE I INO.
INHERITANCE TAX
EXPLANATION
OF CHANGES
2111-0544
11130160
EXPLANATION OF CHANGES
Changed tax rate from 15 percent to 4.5 percent since a son is a lineal beneficiary.
ROW
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