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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX
REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION
PO BOX 280601 STATEMENT OF ACCOUNT
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-C v T L L S DATE 03-09-2015
ESTATE OF BRACKBILL ADA A
75 ( 26 P. M 12 r� DATE OF DEATH 03-22-2014
FILE NUMBER 21 14-0324
C Lr. .. COUNTY CUMBERLAND
SRELBAK.ER,. RICHARD C ACN 101
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j„ Amount Remitted
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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 4-
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REV-1607 EX AFP (12-14) ** INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF:BRACKBILL ADA A FILE NO. : 21 14-0324 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: 02-09-2015
PRINCIPAL TAX DUE: 40,697.37
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-03-2014 CDO19232 1,842.11 35,000.00
10-09-2014 CDO19775 .00 3,747.37
10-09-2014 CDO19777 .00 200.00
02-23-2015 REFUND .00 92.11-
TOTAL TAX PAYMENT 40,697.37
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. \�\