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I FILE NUMBER
21
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Q9u'JER
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
q.3
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG.PA 17128-0601
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
. Couch, Gladis S
rATE OF DEATH'UvIM-DO-YEARj : DATE-6n'lIRTH(MM-OD-YEAR)-----
P;';'~~~:~~~SUR\lIVING SPOUSES NAME)LA~;/~~:; ?N1D1MIDDLE INI~-
a~pplemental Return
D 4a. Future Interest Compromise (dale of death after
12-12-82)
[gI 7. Decedent Maintained a Living Trust (Attach
copy of Trust)
o 10. Spousal Poverty Credit (date of death between 0 11.Election 10 tax under Sec. 9113(A) (Allach Sch 0)
,-CO:. . -.::;.;:"';. Co' _ _1?j3}-_9_1__~~~} .-1;;~_5) _.: _ _.: _ _ _::. ___ ':;C',. "",,".,,, """,."""" .,~,',_.,-, ':.'- ':.'."-;:-;,,',, ..."'. ".'- .', :. .'..:, '." ':_ _,-,_-,---,--_"__.-::
. ,.' .... .': ~::::''-'--
.-.--lT1!ISSEcnClJil.MUS1~l$lJClMl!~e'teQ,.AL~.cq~E$"OHOEItC!>1!!!!!.COIl~1~'tI.<\L.r,\,l(.INFQ~M~TIOIf.$I\Q~LP$EPIREI;TEPTG:
~ i t:I~~::(~f :;p~E;ns__ ... ____.. ___ COMPLETE MAILING ADDRESS .-~~_.~~-
1l ~ 'Ahrens Law Offices, P_C 5521 Carlisle Pike
o Q. ~____ _ ___ _ _ Mechanicsburg, PA 17055
tELEPHONE NUMBER
717/697-1800
---- --.... -- .-..- --
-..-. ------..- ....- ---
, 1. Real Estate (Schedule A)
--~
o
~ 6.
,0 9.
Original Return
4. Limited Estate
Decedent Died Testate (Attach copy
of Will)
Litigation Proceeds Received
2. Stocks and Bonds (Schedule B)
3, Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
02
YI;AR
SOCIAL SECURITY NUMBER
-I
124-38-7229
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_ -iSOCIAl SEC~;~I~~~~ OFWILL~_ .
o 3. Remainder Return (date of deaih prior to 12-13-82)
o 5 Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
(1)
None
(2) None
(3) None
----
(4) None
(5) None
(6) 48,854_18 i-<'
(7) 59,310.51
(8) 108,164_69
(9) 4,585_00
(10)
(11)
4,585.00
(12)
103,579.69
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election 10 tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
26553
(14)
103,314_16
SEE INSTRUCTIONS ON REVERSE SIDE FOR .<\PPLlCABLE RATES
4,637-19
31.86
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
4,669_05
20_ 0
>>BE SURE TO ~NSWER ALL~ESTI()NS ()N REVE~!E_SliiE AtlD RECHECK MATH <;Z --
Copyright 2000 form software only The Lackner Group, Inc.
15.Amount of line 14 taxable at the spousal tax rate, x ,00 (15)
ortranslers under Sec. 9116(a)(1.2)
z 103,048_63 ,045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
~
~
~
~ 17.Amount of Line 14 taxable at sibling rate 26553 x .12 (17)
~
0
u
~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
Form REV-1500 EX (Rev_ 6-00)
Decedent's Complete Address:
STREET ADDRESS
107 Sgrignoli Lane
f--
CITY
Enola
I STATE
PA
ZIP 17025
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4,669.05
233.45
Total Credits (A + B + C)
(2)
233.45
3. Interest/Penalty if applicable
D. Interest
E. Penalty
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(3) 0.00
(4)
(5) 4,435.60
(5A)
(5B) 4,435.60
TotallnteresUPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Make Check Payable 10: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;..
b. retain the right to designate who shall use the property transferred or its income;..
c. retain a reversionary interest; or ................................................
d. receive the promise for life of either payments, benefits or care? .............................................................
2. If death occurred after December 12,1982, did decedent transfer property within one year of death without
receiving adequate consideration? ................................ ..........................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?..
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?.
Yes No
B ~
B ~
181 0
o 181
o 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I dedare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete. Declaration of
preparer othe~ ~~n the pers()l1al ~E!"esent~~.!s bas-ed on all informatio_r:!_of which prepa_~~ has any knowled~__._
SIGNATURE OF PERSON SPONSIBLE FOR FILING RETURN ADDRESS
Sigler A. Co
107 Sgrignoli Lane
Enola, P A 17025
DATE
ADDRESS
/0 -'/- 0 '-'
DATE -
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Thomas J. Ahrens
ADDRESS
DATE
Pike
PA 17055
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty.one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116
1.2) [72 P.S. ~9116 (a) (1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Couch, Gladis S
I FILE NUMBER
21 -02-
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS
RELATIONSHIP TO DECEDENT
A Sigler A. Couch,
107 Sgrignoli Lane
Enola, P A 17025
Son
B Nancy L. Couch
107 Sgrignoli Lane
Enola, PA 17025
Daughter-in-Law
ITEM
NUMBER
JOINTLY OWNED PROPERTY:
I F~:J~~T \, ~~~ \~rC~~~Tia~~g'e;~~~~~~J~~1~fi;:a~~~~~;;I~~~~~dU~~r I JtiUE 06lfN~T 11t?~9i~) DE:EAD~~0i~~~;:EST
. estate. 1
A -\06-/08/19991 House at 107 Sgrign~1i L;ne,-E~ola, PA --I 146,270.00116:7%1-- 24,427.09
B 06/08/1999 House at 107 Sgrignoli Lane, Enola, PA \ 146,270.001 16.7%1 24,427.09
I
I
\
I
\
I
I
I
I
I
I
\
2
TOTAL (Also enter on line 6, Recapitulation)
48,854.18
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
_._ ___m ____
---" ------. .._-,' --- ---" --- ----- ----- --- --
L
_.._ -, This schedulemust be completed .and med i.f the answer to I any of questions ...!!hrough 4 o-"-"~ 2 ./s ye~
IT '. DESCRIPTION OF PROPERTY A I % OF T
EM I' Include the name of the transferee, their relationship 10 decedent and me dale of transfer. I D TE OF DEATH DECO'S I EXCLUSION 1 TAXABLE VALUE
NUMBER Attach a copy oflhe deed for real estate. VALUE OF ASSET I INTEREST (IF APPLICABLE)
TTra;;-sfe~~ith;~1 year ~f de~th, $ 10,000 to Siglerft:.Cou~ilt 10,000.001 100% 3,0000011--
on 5/1102
I
47,000.00\ 100%
I
2,750.201 100%
1
2,560.31 100%
1
I
I
I
\
I
I
ESTATE OF
Couch, Gladis S
2
Transfer within I year of death, $47,000 to Sigler A. Couch I
M~m I
1
I
I
I
\
I
I
1
I
I
1
I
I
\
I
1
I
1
I
\
I
1
I
I
I
3
Living trust account # 039-3360039915 at Dryfus
4
Living trust account # 51310918] at Commerce Baok
I FILE NUMBER
I
.1
21 -02-
7,000.00
47,000.00
2,750.20
2,560.31
J
TOTAL (Also enter on line 7, Recapitulation)
59,310.51
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
I
I
_I
__._m.___
I FILE NUMBER
1 21 - 02-
COMMONWEALTH OF PENNSYLVANIA
INI-IERITII.NCE TAX RET\JRN
RESIDENT DECEDENT
--------- --- -- - ---
--.. -- -- --- ..- --- ..------ -- --
ESTATE OF C h GI d' S
Que, alS
Debts of decedent must be reported on Schedule I.
ITEM r -- - - - -- - --- -- DESCRI~TION --
~.UMBER I FUNERAL EXI'ENSES:- - -- -- - - - --
I I Neill Funeral Home, Inc.
I
I
I
I
I
I
I
I
I
B. I ADMINISTRATIVE COSTS:
1. I Personal Representative's Commissions
I
I Social Security Number(s) I ErN Number of Personal Representative(s):
II Street Address
City State Zip
I Year(s) Commission paid
1
2. Attorney's Fees Ahrens Law Offices, P.C,
I
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Clairnant Sigler A. Couch
Street Address 107 Sgrignoli Lane
City Enola State P A Zip 17025
Relationship of Claimant to Decedent Son
4. Probate Fees Register of Wills of Cumberland County
I AMOUNT
~ - -..----- -
.
I 270.00
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I 800.00
I 3,500.00
I
I
I
I
I
I
1
I
I
I
I
I
I 15.00
I
I
I
I
I
I 4,585.00
I
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I P A Tax filing fee
.1
TOTAL (Also enter on line 9, Recapitulation)
REV.1513 EX+ (9-00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I
I FILE NUMBER
I 21-02~_________
RELATIONSHIP TO
NUMBER i NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT
-- -- -----.--- --, ,- ---- ,------ ----- ,-- n_ - n_,_____ ----' --'-----t- QQ...NQU.ISt.Irustu(s.)__
I. I TAXABLE DISTRIBUTIONS (include outright spousal distributions) I
I GLADIS S. COUCH LIVING TRUST, dated May 25, 2001, 107 Sgrignoli I Trust
I Lane, Enola, PA I
I
I
I
I
I
I
I
I
I
-
--",------
ESTATE OF
Couch, Gladis S
I AMOUNT OR SHARE
_I _ OF ESTA2:E__
I
\
I
I
\
I
I
\
I
I
5,310.51
II.
\
I
I
I
I
I
I
I
I I'
I \
IEnter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet I
I NON-TAXABLE DISTRIBUTIONS:
IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
IBEING MADE
I
I
\
I
I
lB. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I Houston-Love Memorial Library (Beneficiary of Trust)
I
I
I
I
I
I
I
i
I
I
265.53
TOTAL OF PART JI- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET'
,
265.53
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA.17128-Q601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 001697
DUPLICATE
AHRENS THOMAS J ESQUIRE
5521 CARLISLE PIKE
MECHANICSBURG, PA 17050
-------- fold
ESTATE INFORMATION: SSN: 124-38-7229
FILE NUMBER: 2102-0904
DECEDENT NAME: COUCH GLADIS S
DATE OF PAYMENT: 10/07/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
.
DATE OF DEATH: 07/08/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $4,435.60
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$4,435.60
REMARKS: THOMAS J AHRENS ESQUIRE
CHECK# 91 0
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
\. /?- 9'.5-/
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. ZS0601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
THOMAS J AHRENS
AHRENS LAW OFFICES
5521 CARLISLE PIKE
MECHANICSBURG PA 17nS5
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
-; COUNTY
ACN
11-19-2002
COUCH
07-08-2002
21 02-0904
CUMBERLAND
101
AlIOunt Ruttted
'*'
Rn.1S'UEll.lFI'tU-l!tl
GLADIS
S
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 .....
REv=isiWE"x-AFP-foFcizY-Noi'"IcE-.oriNHEifIi'AiicE-i'"Ain,PPRA"IsEKEN:r;-AL.LOwAN'cE-iiR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
GLADIS S FILE NO. 21 02-0904 ACN 101
ESTATE OF
COUCH
TAX RETURN WAS:
I ACCEPTED AS FILED
( X I CHANGED
SEE
DATE 11-19-2002
ATTACHED NOTICE
If an assess.ent was issued previOUSly, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
15. AaIount of U... 1<t at Spousal rate (15 I
16. AlIOunt of Line 14 taxable .t Lineal/Class A rat. (16)
17. Amount of Line 14 at Sibling rate (17)
18. AMount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
RESERVATION CONCERNING FUTURE INTEREST . SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estat. (Schedule A)
2. stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortvages/Notes Receivable (Schedule DJ
5. Cash/Sank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule f)
7. Transfers (Schedule G)
8. Totel Assets
(11
(21
(31
(41
(51
(61
(71
.00
.00
.00
.00
.00
73.135.00
59.310.51
(81
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. flrleral Expenses/AdII.. Costs/Kisc. ExPenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net V.lue of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subiect to Tax
(91
IlUI
1,085.00
.00
(111
1121
1131
Il<tl
NOTE:
.00 X
131,094.98 X
265.53 X
.00 X
NOTE: To insure proper
credit to your account,
~it the upper portion
of this for_ with your
tax pa~nt.
132,445.51
1 ORIi nn
131,360.51
.00
131,360.51
00 =
045 =
12 =
15 =
.00
5,899.27
31. 86
.00
5,931.13
(191=
TAX CREDITS:
(01 AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-I
PAYMENT MUST BE MADE BY 04-08-2003~. TOTAL TAX CREDIT .00
BALANCE OF TAX DUE 5,931.13
INTEREST AND PEN. .00
TOTAL DUE 5,931.13
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INST.I~TTnN~ l
REV.1411! 9: (U8)
'*'
INHERITANCE TAX.
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 1712a.0601
DECEDENrS NAME
Gladis S Couch
FILE NUMBER
REVIEWED BY
Deborah Washington
ACN
2102-0904
101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
F 1&2 Per deed these two people (son and his wife) are considered one party, or one half
owner of said property, not one third.
H B-3 The claim for family exemption cannot be made against non-probate assets as the
exemption comes from Chapter 31 of the Probate, Estates and Fiduciary Code.
ROW
Page 1
\.., /"}- 9.3 -I
BUREAU OF INDIVIDUAL TAXES
IHtERITANCE TAX DIVISION
KEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
J:NHERJ:TANCE TAX
STATEMENT OF ACCOUNT
*'
IEY-UI7EXIFP e01-ln
THOMAS J AHRENS
AHRENS LAW OFFICES
5521 CARLISLE PIKE
MECHANICSBURG PA
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
Co-:1
ACN
01-13-2003
COUCH
07-08-2002
21 02-0904
CUMBERLAND
101
Allount R..itt.d
GLADIS
S
"-1
,_ 1
170551'
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your eccountl submit the upper portion of this for. with your tax p.ym.nt.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
REY=ir.iWE"CAFP-rilFo3r-----ii..-iNHERiTANCi:--TAif-STATEMENT-O'F-ACCOLiN"i--.i.---------------------
ESTATE OF COUCH GLADIS S FILE NO. 21 02-0904 ACN 101 DATE 01-13-2003
THIS STATENENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAKED ESTATE. SHOWN BELOW
IS A ~RY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYNENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT DR RECORD ADJUSTMENT, 11-19-2002
PRINCIPAL TAX DUE, ,...,........"".,..........
5,931.13
PAYMENTS (TAX CREDITS),
PAY
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
10-07-2002 CDOO1697 233.45 4,435.60
MENT MUST BE MADE BY 04-09-2003*. TOTAL TAX CREDIT 4,669.05
BALANCE OF TAX DUE 1,262.08
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 1,262.08
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1.,
NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ,
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORK FOR INSTRUCTIONS. J
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
AHRENS THOMAS J
5521 CARLISLE PIKE
MECHANICSBURG, PA 17050
n-n.__fold
ESTATE INFORMATION: SSN: 124-38-7229
FILE NUMBER: 2102-0904
DECEDENT NAME: COUCH GLADIS S
DATE OF PAYMENT: 02/03/2003
POSTMARK DATE: 01/23/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 07/08/2002
NO. CD 002113
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1,262.08
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: SGILER A COUCH
CHECK# 912
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
$1,262.08
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
I~- 9~-1
\. BUREAU Of INDIVIDUAL TAXES
INI-ERlTANCE TAX. DIY1SION
DEPT. 2806111
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
XNHERXTANCE TAX
STATEMENT OF ACCOUNT
*'
IEV.UI7EXAFP C01-05)
THOMAS J AHRENS
AHRENS LAW OFFICES
5521 CARLISLE PIKE
MECHANICS BURG PA
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
icl;:OUNTV
ACN
02-18-2003
COUCH
07-08-2002
21 02-0904
CUMBERLAND
101
AlIOunt He.! tied
GLADIS
S
17 D!i 5.
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subnit the upper portion of this for. with your tax pay..nt.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
REv=i6'iWiiCiiFP-foFo3r-----..;;-iNiflfiiiTANC'E--TAX-STATEMEriWOFTccOUNT--;;..---------------------
ESTATE OF COUCH GLADIS S FILE NO. 21 02-0904 ACN 101 DATE 02-18-2003
THIS STATENENT IS PROVIDED TO ADVISE Of THE CURRENT STATUS Df THE STATED ACN IN THE MANED ESTATE. SHOWN BELOW
IS A SUNNARY Df THE PRINCIPAL TAX DUE, APPLICATION Df ALL PAYNENTS, THE CURRENT BALANCE, AND, If APPLICABLE,
A PROJECTED INTEREST fIGURE.
DATE OF LAST ASSESSMENT DR RECORD ADJUSTMENT: 11-19-2002
PRINCIPAL TAX DUE: __.._.__...._._._.____...__
5,931.13
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
10-07-2002 CDOO1697 233.45 4,435.60
01-23-2003 CD002113 .00 1,262.08
TOTAL TAX CREDIT 5,931.13
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AfTER THIS DATE, SEE REVERSE TOTAL DUE .00
.
SIDE FOR CALCULATION Df ADDITIONAL INTEREST.
{ If TOTAL DUE IS LESS THAN $1,
NO PAYNENT IS REQUIRED.
If TDTAL DUE IS REFLECTED AS A "CREDIT" {CRI,
YOU NAY BE DUE A REfUND. SEE REVERSE SIDE Of THIS FORN fOR INSTRUCTIONS. I