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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX DIVISION
PO BOX 280601 S TAT E M
E N T OF ACCOUNT
HARRISBURG PA 17128-0601 RECORDED n__`CE OF
REGISTI ER OF V"
ILLS DATE 06-22-2015
1 fpp ESTATE OF SIPE LOIS J
?015 'LIN 30 PM 3 99 DATE OF DEATH 07-28-2013
FILE NUMBER 21 13-0840
COUNTY CUMBERLAND
MYERS EpM�WJt_lD�� SG CCS{RT ACN 101
301 MARKET ST �l;;jj B C 1 i" C, PA Amount Remitted
Po aox 109 CJh§3�.I,Lt E�� �.,
LEMOYNE PA 17043-0109
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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REV-1607 EX AFP C12-14) *** INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF:SIPE LOIS J FILE NO. 21 13-0840 ACN: 101 DATE: 06-22-2015
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: 05-26-2015
PRINCIPAL TAX DUE: 14,950.20
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
10-22-2013 CDO18298 747.51 15,000.00
06-08-2015 REFUND .00 797.31-
TOTAL TAX PAYMENT 14,950.20
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.