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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-13)
INHERITANCE TAX DIVISION STATEMENT OF ACCOUNT
PO BOX 280601
HARRISBURG PA 17128-0601
DATE 09-29-2014
ESTATE OF KELLY HELEN I
DATE OF DEATH 05-03-2013
FILE NUMBER 21 13-0673
COUNTY CUMBERLAND
CONNELL RICHARD E ACN 101
2303 MARKET ST Amount Remitted
CAMP HILL PA 17011-4627
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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ESTATE OF:KELLY HELEN I FILE NO. : 21 13-0673 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: 05-05-2014
PRINCIPAL TAX DUE: 18,540.64
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID
06-17-2013 CDO17892 927.03 18,000.00
09-19-2014 REFUND .00 386.39C';C=,
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TOTAL TAX PAYMENT 18,540.64
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.