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BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENTINHERITANCE TAX DIVISION DEPARTMENT OF REVENUE
PO Box 2B 6 y�ry(1 � ��� Qt BENEFICIARY FORM ASSETS REV-1604A EX AFP (1I-14)
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DATE 04-20-2015
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DATE OF DEATH 12-02-2012
Gt FILE NUMBER 21 12-1344
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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
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: 13505706
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: FIDELITY INVESTMENTS ACCOUNT NO. : 670146
TYPE OF ACCOUNT: (X) SECURITIES C ) SEC ACCT ( ) STOCK C ) BOND
DOD Valuation .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.000 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 .00 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 C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .0
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.