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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX
REV-1607 IX AFP (12-15)
INHERITANCE Tax DIVISION
PO BOX STATEMENT OF ACCOUNT
HARRISBURG URG PA PA 17128-0601
DATE 09-08-2014
ESTATE OF QUIGLEY BEATRICE R
DATE OF DEATH 08-03-2013
FILE NUMBER 21 13-0887
COUNTY CUMBERLAND
ANDES SAMUEL L
ACN 101
525 N 12TH ST
LEMOYNE PA 17043-1245 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) * a INHERITANCE TAX STATEMENT OF ACCOUNT -
ESTATE OF:QUIGLEY BEATRICE R FILE NO. : 21 13-0887 ACN: 101 DATE: 09-08-2014
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: 08-04-2014
PRINCIPAL TAX DUE: 5,993.24
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID ry
DATE NUMBER INTEREST/PEN PAID (-) c�
09-13-2013 CDO18141 299.66 6,500TA s m n
rn
08-20-2014 REFUND .00 806 '
A
:z r r- rn
�T ;,. � rn m
r � rn Cn 7jo
C
> N f rn
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Y yv
TOTAL TAX PAYMENT 5,993.24
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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