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NOTICE OF INHERITANCE TAX pennsylvania b4-
RP;WNT, ~CALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXff r(J ~ L
INHERITANCE TAX DIVISION pFACTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (12-11)
PO BOX 280601
HARRISBURG PA 17128-0601
2112OCT-9 PM 3: 33 DATE 10-01-2012
ESTATE OF BURLESON ROBERT L
DATE OF DEATH 04-02-2011
FILE NUMBER 21 11-0444
OR > ¢AN v '-c
L;M COUNTY CUMBERLAND
SUSAN H CONF"BERLMD CO., PA ACN 101
2331 MARKET ST APPEAL DATE: 11-30-2012
CAMP H I L L PA 17011-4642 (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 4-
REV-1547 EX AFP (12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE-OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: BURLESON ROBERT LFILE NO.:21 11-0444 ACN: 101 DATE: 10-01-2012
TAX RETURN WAS: CX) ACCEPTED AS FILED ( ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate CSchedule A) (1) 77,500.00
NOTE: To ensure proper
2. Stocks and Bonds CSchedule B) C2) 11,378.64 credit to your account,
3. Closely Held Stock/Partnership Interest CSchedule C) (3) 00 submit the upper portion
of this form with your
4. Mortgages/Notes Receivable (Schedule D) C4) .00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 11,214.74
6. Jointly Owned Property (Schedule F) (6) .0 0
7. Transfers (Schedule G) (7) 169,965.16
8. Total Assets C8) 270,058.54
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 2,930.50
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 8,518.79
11. Total Deductions (11) 11,449.29
12. Net Value of Tax Return C12) 258, 609.25
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .00
14. Net Value of Estate Subject to Tax (14) 258, 609.25
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 (15) .00 X 00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate C16) 258.6n9.29 ,x 045 = 11,637.42
17. Amount of Line 14 at Sibling rate C17) .00 X 12 = .00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) 00 X 15 = .00
19. Principal Tax Due (19)= 11,637.42
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT
AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
07-01-2011 CDO14652 563.16 10,700.00
07-02-2012 CDO16205 .02- 374.28
BALANCE OF UNPAID INTEREST/PENALTY AS OF 07-03-2012 TOTAL TAX PAYMENT 11,637.42
BALANCE OF TAX DUE .00
INTEREST AND PEN. 5.57
TOTAL DUE 5.57
* IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.