HomeMy WebLinkAbout04-06-15 INHERITANCE TAX pennsylvania
BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENT
INHERITANCE TAX DIVISION 10
BENEFICIARY FORM ASSETS DEPARTMENT OF REVENUE
PO BOX 280602 �y /s REV-1604A EX AFP (11-14)
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REGISTER GR WILLS
DATE 03-27-2015
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?013 PSR h41 1 1 94 ESTATE OF GERHOLD ROBIN A
1J t U DATE OF DEATH 05-08-2010
FILE NUMBER 21 10-0527
CLI R,' OF COUNTY CUMBERLAND
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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 4—
REV-1604A EX AFP (11-14)
** INHERITANCE TAX RECORD ADJUSTMENT BENEFICIARY FORM ASSETS **
DATE: 03-27-2015
ESTATE OF: GERHOLD ROBIN A DATE OF DEATH: 05-08-2010 COUNTY: CUMBERLAND
FILE NO. : 21 10-0527 S.S/D.C. NO. : ACN: 11501396
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: FIDELITY ACCOUNT NO. : OP005436-74401
TYPE OF ACCOUNT: CX) SECURITIES C ) SEC ACCT C ) STOCK C ) BOND
DOD Valuation 59,785.87 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.000 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax 59,785.87 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions .00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount 59,785.87 AT THE ADDRESS SHOWN ABOVE.
Tax Due X .00 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Rate .00 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS :
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
TOTAL TAX PAYMENT .00
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. .�V)