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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-13)
INHERITANCE TAX DIVISION
PO BOX 280601 STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601
DATE 06-16-2014
ESTATE OF WERTZ DAVID F
DATE OF DEATH 10-16-2013
FILE NUMBER 21 13-1169
COUNTY CUMBERLAND
FLOWER THOMAS E
ACN 101
10 W HIGH ST
CARLISLE PA 17013-2922 Amount Remitted
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
REV-1607 EX AFP (12-13) ■;■ INHERITANCE TAX STATEMENT OF ACCOUNT XXX
ESTATE OF:WERTZ DAVID F FILE NO. : 21 13-1169 ACN: 101 DATE: 06-16-2014
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: 05-12-2014
PRINCIPAL TAX DUE: 3,251 .81
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
01-08-2014 CDO18625 162.59 3,484.60
05-29-2014 REFUND .00 395.38 o
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TOTAL TAX PAYMENT 3,251 .81
BALANCE OF TAX DUE .00
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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