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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION STATEMENT OF ACCOUNT
PO BOX 2BORPI�QD E D OFFiCE OF
HARRISBURG -06DI
REGIST F'R F �VILLS DATE 06-08-2015
ESTATE OF FORNEY RAY K
?015 JUN 17 lzili-5 Il 93 DATE OF DEATH 12-18-2013
FILE NUMBER 21 14-0005
CLE- OF COUNTY CUMBERLAND
F 0 @ WxYf i t U C 0 LOY I D L ACN 101
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LtrC P
,U PA L.Amount Remitted
1601 K ST NW
WASHINGTON DC 20006-1682
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— ------ --- - --- -
REV-1607 ACCOUNT-f STATEMENT CObAfREV-1607 -ex-iW l7473-----* INHERITANCE k ffA E TAX
ESTATE OF:FORNEY RAY K FILE NO. : 21 14-0005 ACN: 101 DATE: 06-08-2015
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: 4,357.79
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID
03-11-2014 CDO18884 115.79 2,200.00
08-11-2014 CDO19521 .00 2,047.79
12-15-2014 CD020036 .00 337.50
05-20-2015 REFUND .00 343.29-
TOTAL TAX PAYMENT 4,357.79
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" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.