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REV-1548 EX AFP (12-1ll
INHERITANCE TAX OIVIStON ~ I
. ', O'~~DUCTIONS, AND ASSESSMENT OF TAX ON
PO BOX 280601
HARRISBURG PA 17128-0601
JOINTLY
HELD OR TRUST ASSETS
'~i ~~utti ~ b r~ '' J~ DATE 11-20-2012
HAROLD
;!. ESTATE OF MUSSELMAN
DATE OF DEATH 05-01-2012
FILE NUMBER 21 12-1049
~~,~~. ;~~ ~~,t:~r COUNTY CUMBERLAND
2776
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~ SSN/DC 188-32-
12132053
AMANDA ~~1Ai-Y
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MH3 ACN
APPEAL BY DATE:O1-19-2013
235 CLAY RD (See reverse side under Objections)
CARLISLE PA 17015-9468 Amount Renitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T 0:
REGISTER OF WILLS
1 COURTHOUSE SpUARE
CARLISLE PA 17013
CUT ALONG THIS LINE 1 RETAIN LOWER PORTION FOR YOUR RECORDS <"'
REV-1548 EX AFP C12-11)
DEDUCTIONSINANDIASSESSMENTAOFRTAXEONNJOINTLYWHELD OR TRUSTLASSETS OF
DATE: 11-20-2012
ESTATE OF: MUSSELMAN HAROLD DATE OF DEATH:05-O1-2012 COUNTY:CUMBERLAND
FILE NO.: 21 12-1049 S.S/D.C. NO.: 188-32-2776 ACN: 12132053
TAX RETURN WAS: CX) ACCEPTED AS FILED ( ) CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 206539-11
TYPE OF ACCOUNT: ( )SAVINGS (X) CHECKING ( )TRUST ( )TIME CERTIFICATE
DATE ESTABLISHED 01-05-2010
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
739.46
X 0.166
123.25
380.00
.00
Y .045
NOTE: TO ENSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE T0:
"REGISTER OF WILLS, AGENT."
TAX CKhUlIS:
PAYMENT
DATE
RECEIPT
NUMBER
DISCOUNT (+)
INTEREST/PEN PAID (-)
ANOUNT PAID
TOTAL TAX PAYMENT .00
BALANCE DF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. * ~~
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), VOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.