HomeMy WebLinkAbout04-29-15 (5) INHERITANCE TAX i , pennsylvania
BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENT7
INHERITANCE TAX DIVISION DEPARTMENT OF REVENUE
PO BOX 280601 �+ � BENEFICIARY FORM ASSETS REV-1604A EX AFP (11-14)
HARRISBURG PAR E1{}5�6nZD OFFICE Qt
REGISTER OF WILLS
�p 1 DATE 04-20-2015
?a15 'ii � 29 PM i2 16 ESTATE ODEATH 125WAYNE E
02-2012
FILE NUMBER 21 12-1344
CLF<i``ti CF
SALL I E A � A+IAN r�°�� COUNTY CUMBERLAND
31 E TECUMSE lt),AH �. T SSN/DC
31 E T MER ACN 13505709
�UMBE 'NJ�'08248-0000
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE —1 RETAIN LOWER PORTION FOR YOUR RECORDS 4--
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REV-1604A EX AFP (11-143
** 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: 13505709
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 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 (+)
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.