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JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION REV-1604 EX AFP (32-12)
PO BOX 280601
HARRISBURG PA 17128-0601
RECORDED �:f 6_iC r. DATE 05-16-2013
RE015fER 0F ',i'L—;.. ESTATE OF GREEN MICHAEL T
DATE OF DEATH 08-21-2008
7 O CC n FILE NUMBER 21 08-0901
CO 1J 99 FiRV 2111 Fi� = O7 COUNTY CUMBERLAND
�+� SSN/DC 196-48-4639
KRISTEN GREEN CLERA' Or� ACN 08140492
4048 SENECA AVE" �P Amount Remi
CAMP HILL A M'1 CUi _ tted
CUMBERLAND CO., °A
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
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REV-1604 EX AFP (12-12)
INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS X*
DATE: 05-16-2013
ESTATE OF: GREEN MICHAEL T DATE OF DEATH: 08-21-2008 COUNTY: CUMBERLAND
FILE NO. : 21 08-0901 S.S/D.C. NO. : 196-48-4639 ACN: 08140492
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO. : 303655-91
TYPE OF ACCOUNT: ( ) SAVINGS C ) CHECKING ( X) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 04-03-2007
Account Balance .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.500 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax . 00 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions . 00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount .00 AT THE ADDRESS SHOWN ABOVE.
Tax Rate X .045 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Due .00 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE nn
IF PAID AFTER THIS DATE, SEE REVERSE 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.