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~[-(r NOTICE OF INHERITANCE TAX Pennsylvania J ~1
BUREAU OF INDIVIDUAL TAXFJ9.F~J1FNT, ALLOWANCE OR DISALLOWANCE .7
INHERITANCE TAX DIVISION r. DEPARTMENT OF REVENUE
PO Sox 280601 CTIONS AND ASSESSMENT OF TAX
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HARRISBURG PA 17128-0601 REfl J " REV-1547 EX AFP (12-11)
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LrIOOCj -9 P M 3; J,; DATE 10-01-2012
ESTATE OF KOCH ARLENE H
DATE OF DEATH 10-04-2011
U~ FILE NUMBER 21 11-1095
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SUSAN L FALLcGtkE(~~JDV'. Cd PR COUNTY CUMBERLAND
1700 VALLEY GREEN RD ACN 101
APPEAL DATE: 11-30-2012
E T T E R S PA 17319-9685 (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 E--•
REV-1547 EX AFP (12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: KOCH ARLENE HFILE NO.:21 11-1095 ACN: 101 DATE: 10-01-2012
TAX RETURN WAS: ( X) ACCEPTED AS FILED ( ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1) 00
2. Stocks and Bonds (Schedule B) NOTE: To ensure proper
(2) 76,869.30 credit to your account,
3. Closely Held Stock/Partnership Interest (Schedule C) 00 submit the upper portion
(3) .
4. Mortgages/Notes Receivable (Schedule D) of this form with your
(4) .00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 541.15
6. Jointly Owned Property (Schedule F) (6) 14, 704.20
7. Transfers (Schedule G) (7) 229,432.34
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS: (s) 321.546 99
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 2.139.4 1
10. Debts/Mortgage Liabilities/Liens (Schedule I)
(10) 1,755.87
11. Total Deductions
12. Net Value of Tax Return (11) 3,895.28
(12) 17,651.71
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) 310,000 00
14. Net Value of Estate Subject to Tax
(14) 307,651 71
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17,
reflect figures that include the total of ALL returns assessed to da18 te and 19 will
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
(16) 307.6917] x 045 = 13,844.33
17. Amount of Line 14 at Sibling rate
(17) 00 X 12 = .00
18. Amount of Line 14 taxable at collateral/Class B rate (18) 00
19. Principal Tax Due X 15 = 00
TAX CREDITS: (19)= 13,844.33
PAYMENT RECEIPT DISCOUNT
DATE NUMBER INTEREST/PEN PAID AMOUNT PAID
04-03-2012 CDO16207 .00
13,844.33
TOTAL TAX PAYMENT 13,844.33
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 D E~
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.