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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-15)
INHERITANCE TAX DIVISION
PO BOX 280601 STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601.
DATE 09-29-2014
ESTATE OF SHIREY CHRISTA
DATE OF DEATH 07-07-2012
FILE NUMBER 21 12-0752
COUNTY CUMBERLAND
SHIREY THOMAS N ACN 101
1937 MISTY WOODS DR
Amount Remitted
DULUTH GA 30097-7961
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 -— - - - - - - - - - - - - - -
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il�V-liif EX 3) INHERITANCE TAX
ESTATE OF:SHIREY CHRISTA FILE NO. : 21 12-0752 ACN: 101 DATE: 09-29-2014
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: 07-07-2014
PRINCIPAL TAX DUE: 18,439.00
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID
01-07-2014 CDO18623 415.80- 19,707.00 r-0
09-11-2014 REFUND .00 852.20
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TOTAL TAX PAYMENT 18,439.00
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.