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BUREAU OF INDIVIDUAL TAXES r±f_Ct1;;~i -IVY l F ~nG
INHERITANCE TAX DIVISION f~~i`'1'f ~ (,r i ~~RITANCE TAX
PO BOX 280601 ~'=~"~'~-'L~~ SR1f~MENT OF ACCOUNT
HARRISBURG PA 17128-0601
~3E?QCT 26 d.. 11= 36
GEORGE B FALLER C~MBERLA~VD CO., Pfd
10 E HIGH ST
CARLISLE PA 17013-3015
Pennsylvania ~
DEPARTMENT OF REVENUE
REV-160] EX AFP (12-ill
DATE lo-2z-zolz
ESTATE OF FALLER URSULA E
DATE OF DEATH 10-21-2010
FILE NUMBER 21 10-1079
COUNTY CUMBERLAND
ACN 101
Amount Remlttetl
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: Tp ensure proper eretlit Yo your account, submit the upper portion of this form with your tax payment.
CUT ALON6 THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS (-~
________________________________________________
REV-1607 EX AFP C12-11) ^~~ INHERITANCE TAX STA 7EMENT OF ACCOUNT ^x^ ----"
ESTATE OF:FALLER URSULA E FILE NO.: 21 10-1079 ACN: 101 DATE: 10-22-2012
THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL
TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-10-2012
PRINCIPAL TAX DUE:
PAYMENTS CTAX CREDITS):
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
01-20-2011 CD013922 394.74 7,500
00
07-20-2011 CD014737 00 .
05-01-2012
CD015914 .
28
07- 2,000.00
10-04-2012
REFUND . 1,375.00
.00 145.92-
TOTAL 7AX PAYMENT 11,095.75
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
.00
~ IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.
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