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BUREAU OF INDIVIDUAL ,~41 -.
INHERITANCE TAX ^IVISION ,.v-~'rcir'~ lp;. '.~~~' C
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HARRISBURG PA 17128-0601
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CHARLES E SHIELDS III
6 CLOUSER RD
MECHANICSBURG PA 17055-9751
DATE 09-24-2012
ESTATE OF CLOUSER RICHARD E
DATE OF DEATH 05-28-2010
FILE NUMBER 21 10-0589
COUNTY CUMBERLAND
ACN 101
Amount Remittetl
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: To ensure proper credit to your account, submit the upper portion of this form with Your tax payment.
CUT ALONG THIS LINE __ ____ ~__RETAIN LOWER~PORTION~FOR_YOUR~ RECORDS_
REV-1593 EX AFP C12-11J ^^ INHERITANCE TAX RECORD ADJUSTMENT ~*
:21 10-0589
LE N0
E ACN: 101 DATE: 09-24-2012
ESTATE .
FI
OF:CLOUSER RICHARD
ADJUSTMENT BASED oN: ADMINISTRATIVE CORRECTION
VALUE OF ESTATE: (1)
1 904.00
7
1. Real Estate (Schedule A) ) 00
) (2 .
2. Stocks and Bonds (SChetlule B (3) 00
3 Closely Held Stock/Partnership Interest (Schedule C) .
.
hedule D)
(S (4) .DO
4 c
Mortgages/Notes Receivable
.
nal Property (Schedule E) 4.821.98
5. Cash/Bank Deposits/Misc. Perso (6)
le F)
d 16.193.18
6. u
Jointly Owned Property (Sche
I7) .00
7. Transfers (Sch¢dule G) (e) 92,919.16
e. Total Assets
DEDUCT IONS AND EXEMPTIONS:
9. Funeral Expenses/Adminiskrative Costs/ 57
424.82
Miscellaneous Expenses (Schedule H) (9)
Ilo) ,
~-
1,280.31
10 Debts/Mortgage Liabilities/L1¢ns (Schedule I7 58
13
705
. (11) ,
.
11. Total Deductions (lp) 34,214.03
12. Net Value of Tax Return
Nan-elacte d. 9113 Trusts
t
(Schedule
J) .00
13. s;
Charitable/Governmental Beques ] 214.03
34
14 . Net Value of Estate Subject to Tax (14 ,
TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rata
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS: ~~~~~w ,y~
(15) .00X.00 = .00
(1B) 55,449.44X.045= 2,495.22
(n) .00X.12 .00
(1e) .00X.15 = .00
c19) 2,495.22
AMOUNT PAID
PAxneni •~----
DATE NUMBER INTEREST/PEN PAID (-)
124.76 2,992.50
08-13-2010 CD013210 00 519.49-
07-05-2012 REFUND
TOTAL TAX PAYMENT 2,597.77.
IALANCE OF TAX DUE 102.55(
INTEREST AND PEN. .00
_„~., .,.,~ .102.55(
INHERITANCE TAX Pennsylvania ~....
RECORD ADJUSTMENT DEPARTMENT OF REVENUE
REV-1593 EX AFP (12-ill
IF PAID AFTER DATE INDICATED. SEE REVERSE IF TOTAL DUE IS REFLECTED A5 w "~neuii- ~~~• •-•
* FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INST
INHERITANCE TAX
EXPLANATION
OF CHANGES
21 10-0589
101
ITEM EXPLANATION OF CHANGES
SCHEDULE NO.
A 1 The value of the real estate has been adjusted to reflect the sale value as indicated on t e
HUD-1 settlement sheet provided by the estate. The value was initially suspended on the
original return.
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