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ITANCE TAX pennsylvania 0
BUREAU OF INDIVIDUAL TAXES ADJUSTMENT
INHERITANCE TAX DIVISION DEPARTMENT OF REVENUE
PO BOX 280601 t J,~B {E ! d: ' RY FORM ASSETS REV-1604A EX AFP (12-11)
HARRISBURG PA 17128-0601
Z212 AUG 13 FM 12: 2- DATE 08-01-2012
ESTATE OF WOLF ROGER A
DATE OF DEATH 08-07-2011
- FILE NUMBER 21 11-0970
ORPHA J W, %Jii~ COUNTY CUMBERLAND
FREDERICK E WOLF CUMBER ID CO., PA SSN/DC 199-34-9504
649 OLD YORK RD ACN 11502647
ETTERS PA 17319-8819
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS
REV-1604A EX AFP (12-11)
INHERITANCE TAX RECORD ADJUSTMENT BENEFICIARY FORM ASSETS
DATE: 08-01-2012
ESTATE OF: WOLF ROGER A DATE OF DEATH: 08-07-2011 COUNTY: CUMBERLAND
FILE NO.: 21 11-0970 S.S/D.C. NO.: 199-34-9504 ACN: 11502647
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: AMERIPRISE ACCOUNT NO.: 000074232448602
TYPE OF ACCOUNT: (X) SECURITIES C ) SEC ACCT C ) STOCK ( ) BOND
DOD Valuation .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.333 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax 00 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions - 00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount 00 AT THE ADDRESS SHOWN ABOVE.
Tax Due X .12 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Rate 00 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
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.