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BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX
INHERITANCE TAX DIVISION APPRAISEMENT, ALLONANCE OR DISALLORANCE pennsylvania
PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON DEPARTMENT OF REVENUE
HARRISBURG, PA 17128-0601 SECURITY ACCOUNTS HELD IN
BENEFICIARY FORM REV-15a8A AFP (12-12)
0r
DATE 12-24-2012
ESTATE OF AMMERMAN HELEN 0
DATE OF DEATH 06-09-2011
n 21 ~rl FILE NUMBER 21 11-0801
L 1 COUNTY CUMBERLAND
v. SSN/DC 153-16-4575
LEE 0 AMMERMAW, ;:F~y (D
i' ACN 12503926
930 PINETOWN RD ~`+r APPEAL BY DATE: 02-22-2013
d~tHAS
L E W I S B E R R Y 7r7 pi p (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-1548A AFP C12-12)
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS
AND ASSESSMENT OF TAX ON SECURITY ACCOUNTS HELD IN BENEFICIARY FORM
DATE: 12-24-2012
ESTATE OF:AMMERMAN HELEN 0 DATE OF DEATH: 06-09-2011 COUNTY: CUMBERLAND
FILE NO.: 21 11-0801 S.S/D.C. NO.: 153-16-4575 ACN: 12503926
TAX RETURN WAS: (X) ACCEPTED AS FILED C )CHANGED
BENEFICIARY FORM OF ASSET INFORMATION
NAME OF SECURITY: WELLS FARGO ACCOUNT NO.: 3501761939
TYPE OF ASSET: C ) SECURITIES C ) SECURITY ACC (X) STOCK C ) BONDS
DOD Valuation 6,336.00 NOTE: TO ENSURE PROPER CREDIT TO
Percent Taxable X 0.333 YOUR ACCOUNT, SUBMIT THE
Amount Subject to Tax 2,111.98 UPPER PORTION OF THIS NOTICE
Debts and Deductions - .00 WITH YOUR TAX PAYMENT TO THE
Taxable Amount 2,111.98 REGISTER OF WILLS AT THE
Tax Rate X .045 ABOVE ADDRESS. MAKE CHECK
Tax Due 95.04 OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
INTEREST IS CHARGED THROUGH 01-01-2013* TOTAL TAX PAYMENT .00
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 95.04
REVERSE SIDE OF THIS FORM INTEREST AND PEN. 2.32
TOTAL DUE 97.36
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. u
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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