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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
JACQUELIN A KELLY
STE 12
845 SIR THOMAS CT
HBG PA 17109
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-28-2005
FORD
10-16-2004
21 05-0038
CUMBERLAND
101
Allount Rellitted
'*
REV-1547 EX AFP (03-05)
AMY
L
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
1!t'!--.t!~"Yf.WJ.m~'U!1.'Wfm.w.nIMAW4M!r.tx't.lWltlmMMf~.YJ:UN'4AtY.r.W'.............. ...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF FORD AMY L FILE NO. 21 05-0038 ACN 101 DATE 03-28-2005
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
NOTE: To insure proper
credit to your account,
submit the upper portion
of this for.. with your
tax paYllent.
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
U)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
681.13
5,751.96
5,929.50
(8)
(9)
UO)
2,915.97
12,362.59
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governll8ntal Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
1.825.40
Ul)
(2)
(13)
(4)
4.741 37
7,621.22
.00
7,621.22
NOTE:
I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
AX C E ITS:
.00 X
7,621.22 X
.00 X
.00 X
00 =
045 =
1~2 =
15 ; ';..;<
.':""!lJ
(9)=' c:
DATE
01-12-2005
+
INTEREST/PEN PAID (-)
17 .15
AMOUNT PAID
325.80
NUMBER
CD004838
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER DATE INDICATED, SEE REVERSE
fOR CALCULATION OF ADDITIONAL INTEREST.
.00
;,..,342.95
c.;;:, . OIL;
:.....
.0,(1)
,,342 .9'5 ;
-.,., , . . .
C""'
Ul
342.95
.00
.00
.00
{ IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~ "5 "'"