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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1687 Et AFP (12-13)
Br2 TAX nivlslON
PO BOX 2806 Bi STATEMENT OF ACCOUNT
PO 806
HARRISBURG PA 17128-0601
DATE 06-23-2014
ESTATE OF FRY ANN H
DATE OF DEATH 01-07-2013
FILE NUMBER 21 13-0131
DOLAN LESLIE M COUNTY CUMBERLAND
ACN 101
414 BLACKLATCH LN Amount Remitted
CAMP HILL PA 17011-8414
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 ft—) RETAIN LOWER PORTION FOR YOUR RECORDS 4—
- - - - - - - - - - - - - -
REV-1607 EX AFP C12-33) ��* INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF:FRY ANN H FILE NO. : 21 13-0131 ACN: 101 DATE: 06-23-2014
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: 9,267.29
PAYMENTS (TAX CREDITS):
c ITT
PAYMENT RECEIPT DISCOUNT C+) o c_ rn
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID r? Z
_ S �
04-02-2013 CDO17389 463.36 10,808.98 rrI �.A? nz n
06-03-2014 REFUND .00 2,005.05-
n CJ
o Z3 �E
ITT
s o
r+
TOTAL TAX PAYMENT 9,267.29
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.