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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-12)
INHERITANCE TAX DIVISION
PO BOX 280601 STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601 ~r/y
REC
DATE 12-17-2012
R EG1-a . - 0 ESTATE OF COUSART SARA N
DATE OF DEATH 05-31-2012
+`,21 r
I? FILE NUMBER 21 12-0632
COUNTY CUMBERLAND
GLENN A SCHAEFFER ACN 101
3873 LARABY DR CLERK
Amount Remitted
HARRISBURG PA 109F&LU-6 C.
Ef
CUMBEBLA '.6
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
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 4-
REV-1607 EX AFP C12-12~ INHERITANCE TAX STATEMENT OF ACCOUNT
ESTATE OF:000SART SARA N FILE NO.: 21 12-0632 ACN: 101 DATE: 12-17-2012
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: 11-05-2012
PRINCIPAL TAX DUE: 5,794.08
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
08-13-2012 CDO16375 288.90 5,489.14
11-26-2012 CDO16835 .00 16.04
TOTAL TAX PAYMENT 5,794.08
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" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.