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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION STATEMENT OF ACCOUNT
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HARRISBUR WI-71:28-0601 - ' r .L� F
R E"i 12,T L L S DATE 03-09-2015
ESTATE OF BURGETT F C
niu iro, n DATE OF DEATH 04-17-2013
FILE NUMBER 21 13-0519
COUNTY CUMBERLAND
G
ACN 101
r",.M CKNIGHT PC- mount Remitted
60 W POMFRET ST
CARLISLE PA 17013-3243
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
I 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 4—
I - -9f E;E ACCOUNT **-- - - - -- - -- - -- -- -
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ESTATE OF:BURGETT F C FILE NO. : 21 13-0519 ACN: 101 DATE: 03-09-2015
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: 02-02-2015
PRINCIPAL TAX DUE: 149,579.09
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
07-17-2013 CDO17896 7,478.95 150,000.00
02-20-2015 REFUND .00 7,899.86-
TOTAL TAX PAYMENT 149,579.09
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.