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RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES REV-1604 EX AFP (12-13)
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
DATE 03-04-2014
ESTATE OF MENTZER SR RUSSELL E
DATE OF DEATH 12-04-2012
FILE NUMBER 21 13-0091
COUNTY CUMBERLAND
SSN/DC
BETTY E MENTZER ACN 12167823
37 KENWOOD AVE Amount Remitted
CARLISLE PA 17013-3125
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—
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REV-1604 EX AFP (12-13)
x* INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS
DATE: 03-04-2014
ESTATE OF: MENTZER SR RUSSELL E DATE OF DEATH: 12-04-2012 COUNTY: CUMBERLAND
FILE NO. : 21 13-0091 S.S/D.C. NO. : ACN: 12167823
ADJUSTMENT BASED ON : ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: SUSQUEHANNA BANK ACCOUNT NO . : 290005937
TYPE OF ACCOUNT: ( ) SAVINGS C ) CHECKING ( ) TRUST ( X) TIME CERTIFICATE
DATE ESTABLISHED 04-09-2009
Account Balance •00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0. 166 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 ABQV€.
Tax Rate X •00 MAKE CHECK OR MOEY ORDEI(' PAYAB6&
Tax Due • 00 TO: 'REGISTER (ILLS, GEtg�'Z'j
TAX CREDITS: Z,
PAYMENT RECEIPT DISCOUNT C+7 z
DATE NUMBER INTEREST/PEN PAID C-7 AMOUNT PAID C15
DATE
12-06-2013,1 CDO18495 .00 2,537.42 C-); : -0
12-13-2013 SBADJUST .00 1 .86 O 3' " aD
r.� 1Te
tV -;
l
r
TOTAL TAX PAYMENT 2,539.28
BALANCE OF TAX DUE 2 539.28CR
INTEREST AND PEN. .00
TOTAL DUE
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. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
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