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INHERITANCE TAX
RECORD ADJUSTMENT pennsytvania
JOINTLY HELD OR TRUST ASSETS IV DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISIONREV-1604 EX AFP (11-14)
PO BOX 280
HARRISBURG601 PA 17128-0601 RECORDED OF
RL G _6 DATE 03-02-2015
RR ESTATE OF TOLLEY HOWARD E
� fi10 pj� 1 DATE OF DEATH 04-28-2013
FILE NUMBER 21 14-1120
COUNTY CUMBERLAND
CLEF SSN/DC
ANN E KUL PORP11114-1' ACN 13171717
5720 KENT OWWD
C�?T--- 1 - I Amount Remitted
HARRISBURG �A-17112 I
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 E—
REV-1604 EX AFP (11-14)
INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS
DATE: 03-02-2015
ESTATE OF: TOLLEY HOWARD E DATE OF DEATH: 04-28-2013 COUNTY: CUMBERLAND
FILE NO. : 21 14-1120 S.S/D.C. NO. : 564-20-5618 ACN: 13171717
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ACNB BANK ACCOUNT NO. : 2355442
TYPE OF ACCOUNT: ( ) SAVINGS ( X) CHECKING C TRUST TIME CERTIFICATE
DATE ESTABLISHED 01-11-2010
Account Balance 26,981 .70 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.166 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax 4,497.04 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions .00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount 4,497.04 AT THE ADDRESS SHOWN ABOVE.
Tax Rate X .045 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Due 202.37 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS :
PAYMEDATENT RNUMBER ECEIPT INTERESTDISC/PENN PAID
OUT AMOUNT PAID
INTEREST IS CHARGED THROUGH 03-17-2015 TOTAL TAX PAYMENT .00
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 202.37
REVERSE SIDE OF THIS FORM INTEREST AND PEN. 6.85
TOTAL DUE 209.22
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.