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—I DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION
PO BOX 28060 MCE OF STATEMENT OF ACCOUNT
n-D Cr r
HARRISBURG PA IMIQ P6 A
R E DATE 05-18-2015
7015 26 12 52 ESTATE OF DAVIS DAVID A
DATE OF DEATH 05-15-2014
C LE CT FILE NUMBER 21 14-0507
COUNTY CUMBERLAND
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SANDRAOR P jb,�,t;NTf'D N ACN 14136348
16 Ctkfpt),RWOOD'COVE i' '6
i+ — I Amount Remitted
FOGELSVILLE PA 18051
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 4— - -- - --- - - - - - --
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i[REV-1607 _ex_AFP _CH 174-3---- -*;;_fWHHffA�NE TAX HAYE;ilif OF i6CiHif
ESTATE OF:DAVIS DAVID A FILE NO. : 21 14-0507 ACN: 14136348 DATE: 05-18-2015
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: 05-18-2015
PRINCIPAL TAX DUE: .11
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
05-15-2015 SBADJUST .00 .11
TOTAL TAX PAYMENT .11
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
IF PAID AFTER THIS DATE, SEE REVERSE SIDE 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.