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—V DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISIONiff,. I-
PO Box 280601 1' 1 FICE OPTATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601
7 ILLS
DATE 03-30-2015
?nlS RPR 6 Hm 1143 ESTATE OF GARBACIK RAYMOND R
DATE OF DEATH 02-08-2013
CLERK OF FILE NUMBER 21 13-0194
RICHARD OapdM1 k-CI(KOQRT, COUNTY CUMBERLAND
ACN 14101755
221 N ltN9ERtM,,llD Goo, �4d
Amount Remitted
CAMP HILL PA 17011-3911 - �I
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
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ESTATE OF:GARBACIK RAYMOND R FILE NO. : 21 13-0194 ACN: 14101755 DATE: 03-30-2015
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: 03-13-2015
PRINCIPAL TAX DUE: 2,943.56
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID
05-08-2013 CDO17584 147.18 2,796.83
12-23-2014 CD020068 .00 24.99
TOTAL TAX PAYMENT 2,969.00
BALANCE OF TAX DUE 25.44CR
INTEREST AND PEN. .00
TOTAL DUE 25.44CR _
IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.