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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION T7 STATEMENT OF ACCOUNT
PO BOX 280601 �F
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DATE 05-26-2015
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7gjs JUN 2 RF, -1 "312 ESTATE OF WAULTERS DARLIS D
DATE OF DEATH 03-17-2014
F, FILE NUMBER 21 14-0337
HAL BRU@W Mt�',�'MA� kK' E COUNTY CUMBERLAND
ACN 101
2109 (!bAP,KF--T-ST
,jt-�, - I Amount Remitted
CAMP HILL PA 17011-4723
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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ESTATE OF:WAULTERS DARLIS D FILE NO. : 21 14-0337 ACN: 101 DATE: 05-26-2015
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: 04-27-2015
PRINCIPAL TAX DUE: 32,410.66
PAYMENTS CTAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
06-13-2014 CDO19301 1,620.53 30,800-00
05-11-2015 REFUND .00 9.87-
TOTAL TAX PAYMENT 32,410.66
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.