HomeMy WebLinkAbout04-29-15 INHERITANCE TAX pennsyLvania
BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENT DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION 11�
PO BOX 280601 BENEFICIARY FORM ASSETS REV-1604A EX AFP (11-14)
HARRISBURG PA RTE26-OR0 rL---ID 0,F F I C E 0 F
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REGISTEn,% WILLS DATE 04-20-2015
NOS
HIS APR 29 PF1 12 15 DATEESTATE OFOF DEATH 12502-2012 WAYNE E
FILE NUMBER 21 12-1344
F"' OF COUNTY CUMBERLAND
KATHLEEN N MU �EW'' I r- z I-I- SSN/DC
585 SPRING L04MAN,IS, I - ACN 13505707
BOILING S"@:!.{BF-FPk 170.07-9640 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-
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REV-1604A EX AFP (11-14)
INHERITANCE TAX RECORD ADJUSTMENT BENEFICIARY FORM ASSETS
DATE: 04-20-2015
ESTATE OF: NOSS WAYNE E DATE OF DEATH: 12-02-2012 COUNTY: CUMBERLAND
FILE NO. : 21 12-1344 S.S/D.C. NO. : ACN: 13505707
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: FIDELITY INVESTMENTS — ACCOUNT NO. : 670146
TYPE OF ACCOUNT: (X) SECURITIES C SEC ACCT C ) STOCK C ) BOND
DOD Valuation .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.200 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax .00 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions .00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount :Do AT THE ADDRESS SHOWN ABOVE.
Tax Due X .045 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Rate .00 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS :
PAYMENT RECEIPT DISCOUNT
DATE NUMBER INTEREST/PEN PAID 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.