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BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX
INHERITANCE TAX DIVISION APPRAISEMENT ALLONANCE OR DISALLONANCE pen nsylvarn•
a
PO BM 280601 OF DEDUCTIQ i-�a,AND ASSESSMENT OF TAX ON
HARRISBURG, PA 17128-0601 R F f j O R Z,i_-1 i SECU; "1"7CJACCOUNTS HELD IN DEPARTMENT OF REVENUE
TO
_ _ B EFICIARY FORM REV-1548A AFP (11-141
DATE 03-09-2015
,Lilt t 1gi1 10 FM I 28 ESTATE OF LANDIS JOHN G
1J DATE OF DEATH 03-12-2014
FILE NUMBER 21 14-0304
G!-L; COUNTY CUMBERLAND
SSN/DC
JOHN R LANDIS �tlPtlr"' ACN 15500190
467 REECE DR CUVD; P APPEAL BY DATE: 05-08-2015
HOSCHTON GA 30548-4321 (See reverse side under Objections)
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE —► RETAIN LOWER PORTION FOR YOUR RECORDS
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REV-1548A AFP C11-14)
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS
AND ASSESSMENT OF TAX ON SECURITY ACCOUNTS HELD IN BENEFICIARY FORM
DATE: 03-09-2015
ESTATE OF:LANDIS JOHN G DATE OF DEATH: 03-12-2014 COUNTY: CUMBERLAND
FILE NO. : 21 14-0304 S.S/D.C. NO. : ACN: 15500190
TAX RETURN WAS: (X) ACCEPTED AS FILED C )CHANGED
BENEFICIARY FORM OF ASSET INFORMATION
NAME OF SECURITY: AMERICAN STOCK TRANSFER ACCOUNT NO. : SUSQ
TYPE OF ASSET: ( ) SECURITIES C ) SECURITY ACC (X) STOCK C ) BONDS
DOD Valuation 5,240.66 NOTE: TO ENSURE PROPER CREDIT TO
Percent Taxable X 0.500 YOUR ACCOUNT, SUBMIT THE
Amount Subject to Tax 2,620.33 UPPER PORTION OF THIS NOTICE
Debts and Deductions - .00 WITH YOUR TAX PAYMENT TO THE
Taxable Amount 2,620.33 REGISTER OF WILLS AT THE
Tax Rate X .045 ABOVE ADDRESS. MAKE CHECK
Tax Due 117.91 OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
01-21-2015 CD020169 .00 117.91
03-02-2015 SBADJUST .00 .39
TOTAL TAX PAYMENT 117.91
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER THIS DATE, SEE REVERSE 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. (vim/