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INHERITANC� TAX �. pennsy van�a
RECORD ADJUSTMENT DEPARTMENTOFREVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION REV-1593 D( AFP C12-12)
PO BOX 280601
HARRISDUR6 PA 17128-0601
DATE 09-25-2013
ESTATE OF DAVIS GEORGE S
DATE OF DEATH 08-02-2011
FILE .NUMBER 21 11-0960
COUNTY CUMBERLAND
ACN 101
REAGER DAVID W Amount Remitted
2331 MARKET ST
CAMP HILL PA 17011-4642 MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: To snsure proper credit to your account, submit the uppQr portion of this forn� with your tax payment.
CUT ALON6 THIS LINE -�-► RETAIN LOWER PORTION FOR YOUR RECORDS E�
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REV-1593 EX AFP C12-12? ** INHERITANCE TAX RECORD ADJUSTMENT **
ESTATE OF:DAVIS GEORGE S FILE N0. :21 11-0960 ACN: 101 DATE: 09-25-2013
ADJUSTMENT BASED ON: PROTEST BOARD DECISION
VALUE OF ESTATE:
1. Real Estate CSchedule A) C1� 71,300.00
2. Stocks and Bonds tSchedule B) �2� .0 0
3. Closely Held Stock/Partnership Interest CSchedule C) �3) 207,026.00
4. Mortgages/Notes Receivable CSchedule D) �4? .0 0
5. Cash/Benk DlpositsfMisc. Personal Prop�rty CSchedule E) �5) 181,475.67
6. Jointly Owned Property CSchedule F) C6) ��
.0 0 �' ;� �
7. Transfers CSchedule G) C7) � �� � E'�'1 �
8. Total Assets "^� C8� � ��p801.67
W -�� �_.
DEDUCTIONS AND EXEMPTIONS: � � � ,.,� ��
9. Fun�ral Expenses/Administrative Costs/ � �"' r �
r"' -� i'�'1 --,J � 'C�
Miscallaneous Expenses CSchedule H) C9) 17,�i�"8�� �, C�
10. Debts/Mortgaga Liabilities/Liens (Schedule I) (10) 2, �_� "'� "� �
il. Total Daductions � �('�'j) � �9e�04:69
12. Net ValuQ of Tax Return ;�
�ci2� f-�" 9;�96:98
13. Charitable/GovQrnmental Bequests; Non-elected 9113 Trusts CSchedule J) .� "�(13) Q .:0 0
14. Nat Value of Estate Subject to Tax �' C14) 439,996.�`98
TAX:
15. An�ount of Line 14 at Spousal rate
ci5) 439,996.98X.00 � .00
16. Amount of �ine 14 taxable at Lineal/Class A rate C16� .00 Y.045a .00
17. A�aount of Lina 14 at Sfbling rate C17) .00Y.12 = .00
18. Amount of Line 14 taxable at Collateral/Class B rate {ig� .0 0 Y.1 5 ` .0 0
19. Principal Tax Due C19)
TAX CREDITS: .00
+ AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
TOTAL TAX PAYMENT .00
ALANCE OF TAX DUE ' .00
INTEREST AND PEN. .00
TOTAL DUE .OD
* IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLEGTED AS A "CREDIT" CCR), YOU MAY BE DUE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)