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NOTICE OF INHERITANCE TAX pennsylvania
t94M LOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES r~ 1° iL3t.
INHERITANCE TAX DIVISION PROF ?'DEWCTX19 AND ASSESSMENT OF TAX REV-1547 EX AFP (12-11)
PO BOX 280601
HARRISBURG PA 17128-0601
4012 GCT _9 PM 3:3 1 DATE 10-08-2012
ESTATE OF BLACK JOHN L
DATE OF DEATH 10-11-2011
FILE NUMBER 21 11-1135
~±ORPHANS COURT COUNTY CUMBERLAND
RONALD E JOHNSON E4UMBERL.AND CO., PA ACN 101
78 W POMFRET ST APPEAL DATE: 12-07-2012
CARLISLE PA 17013-3216 (See reverse side under Objections)
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-1547 EX AFP (12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: BLACK JOHN LFILE NO.:21 11-1135 ACN: 101 DATE: 10-08-2012
TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED
APPRAISED VALUE OF RETURN BASED ON. ORIGINAL RETURN
1. Real Estate CSchedule A) Cl) 52, 000.00 NOTE: To ensure proper
2. Stocks and Bonds (Schedule B) C2) .00 credit to your account,
submit the upper portion
3. Closely Held Stock/Partnership Interest (Schedule C) (3) 00 of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property CSchedule E) C5) 15,69 3.74
6. Jointly Owned Property (Schedule F) C6) .00
7. Transfers (Schedule G) C7) 5,534.29
8. Total Assets (8) 73,228.03
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 27,321.55
10. Debts/Mortgage Liabilities/Liens CSchedule I) C10) 4,417.68
11. Total Deductions C11) 31,739.23
12. Net Value of Tax Return C12) 41,488.80
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts CSchedule J) (13) .00
14. Net Value of Estate Subject to Tax (14) 41,488.80
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate C15) .0 0 X 00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 41 .488.8n x 045 = 1,867.70
17. Amount of Line 14 at Sibling rate (17) _nn X 12 = .00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 = .00
19. Principal Tax Due C19)= 1,865.20
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
07-11-2012 CDO16244 .00 1,865.20
TOTAL TAX PAYMENT 1,865.20
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DU
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.