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pennsylvania
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
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PO BOX 28 t ll OFFICE OF STATEMENT OF ACCOUNT
HARRISBURG ��JII2' 60 �
WILLS L S
(j CI DATE 07-27-2015
?015 AUG 3 PM 12 03 ESTATE OF CLOUSER DAVID H
DATE OF DEATH 02-20-2009
CLERK OF FILE NUMBER 21 09-0204
COUNTY CUMBERLAND
PA09&6"ANS' C C(AlICHAEL 0 ACN 101
OVUBfRtLND,LE) RD• Amount Remitted
CAMP HILL PA 17011-4432
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
REV-1607 EX AFP C12-14) *** INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF:CLOUSER DAVID H FILE NO. : 21 09-0204 ACN: 101 DATE: 07-27-2015
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: 06-29-2015
PRINCIPAL TAX DUE: 7,040.54
PAYMENTS CTAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-15-2009 CDO11247 352.03 7,000.00
07-13-2015 REFUND .00 311 .49-
TOTAL TAX PAYMENT 7,040.54
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. \�\
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