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BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENT DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
PO BOX 280601 BENEFICIARY FORM ASSETS —=
HARRISBURG PA RE907RSIE O OFFICE O F REV-1604A IX AFP (11-14)
REGISTER OF WILLS
DATE 04-20-2015
?nU1S RPR 27� P(� 12 16
1 c ESTATE OF NOSS WAYNE E
v DATE OF DEATH 12-02-2012
FILE NUMBER 21 12-1344
CLEF,ti 0 F COUNTY CUMBERLAND
DONALD A NOSS SSN/DC
110 HEMLOCKOIE HAr ��` E
PA
"T"`73•T9_;1'4.`94 ACN 13505708
ETTERS
CUMBER'E 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 E—
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: 13505708
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
BENEFICIARY FORM ASSETS
NAME OF SECURITY: FIDELITY INVESTMENTS ACCOUNT NO. : 670146
TYPE OF ACCOUNT: (X) SECURITIES ( ) 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 .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+)
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" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.