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DEPARTMENT OF REVENUE
BUREAU OF TAX IN Dj:as0FF,I0E OF INHERITANCE TAX REV-1607 EX AFP (12-13)
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PO BOX 280601STER Of WILLS STATEMENT OF ACCOUNT
HARRISBURG PA 171 O1
Z�jl DEC 8 Fill DATE 12-01-2014
ESTATE OF GOVER MATTHEW R
CLERv,-, OF DATE OF DEATH 11-27-2012
FILE NUMBER 21 12-1323
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ANDREgUtABETGUER A ACNCOUNTY 13166393CUMBERLAND
142 ASHFORD WAY
Amount Remitted
CAMP HILL PA 17011-3919
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
-f X-if STATEMENT i6cobif- - ----- - -------
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ESTATE OF:GOVER MATTHEW R FILE NO. : 21 12-1323 ACN: 13166393 DATE: 12-01-2014
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: 10-27-2014
PRINCIPAL TAX DUE: 134.42_
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID -
DATE NUMBER INTEREST/PEN PAID C-)
11-17-2014 CDO19928 4.86- 139.28
11-28-2014 SBADJUST .00 .07
TOTAL TAX PAYMENT 134.42
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.