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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-168] EX AFP [12-13)
INHERITANCE Tax DIVISION STATEMENT OF ACCOUNT
PO BOX
HARRISBURG URG PA PA 17128-0601
DATE 04-21-2014
ESTATE OF WERTZ RICHARD H
DATE OF DEATH 04-27-2013
FILE NUMBER 21 13-0540
OLSEN ESQ LINDA J COUNTY CUMBERLAND
S ACN LOL
TE 202
2000 LINGLESTOWN RD
Amount Remitted
HARRISBURG PA 17110-9347 t
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 F
REV-1607 EX AFP (12-13) ■ ■ INHERITANCE TAX STATEMENT OF ACCOUNT NN
ESTATE OF:WERTZ RICHARD H FILE NO. : 21 13-0540 ACN: 101 DATE: 04-21-2014
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: 03-17-2014
PRINCIPAL TAX DUE: 3,892.39
PAYMENTS (TAX CREDITS) :
n m
PAYMENT RECEIPT DISCOUNT (+) - ITT C->
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID G'> p '.
07-26-2013 CD017948 Ca n
, . ,n . O 4
r ry M
rn rn ;
04-03-2014 REFUND .00 302.23C : ' (1't
2 p O
O T
° C: r
r
j fV Cn T
TOTAL TAX PAYMENT 3,892.39
BALANCE OF TAX DUE .DO
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.
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