HomeMy WebLinkAbout08-17-15 RECORDED OFFICE OF INHERITANCE TAX •
RECORD ADJUSTMENT 'c:;. Pennsylvania
REGIS!LER OF WILLS JOINTLY HELD OR TRUST ASSETS
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES ___.._..
INHERITANCE TAX gIQ�IJ REV-1604 EX AFP (11-14)
PO BOX 280601 / S)
HARRISBURG PA 171 6b v
CLE 11 ; OG 17 Pn 12 39
DATE 08-05-2015
O R P'HA N S' ;'t` ESTATE OF FORTNEY BETTY J
DATE OF DEATH 08-20-2014
CUMDE;RL; `"'7 `, FILE NUMBER =,-a� o -2-145-0743 43
COUNTY CUMBERLAND
DAVID K FORTNEY
SSN/DC
ACN 14148957
9 SKYPORT RD Amount Remitted
MECHANICSBURG PA 17050-2329
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE —1 RETAIN LOWER PORTION FOR YOUR RECORDS (--
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REV-1604 EX AFP (11-14)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE: 08-05-2015
ESTATE OF: FORTNEY BETTY J DATE OF DEATH: 08-20-2014 COUNTY: CUMBERLAND
1z W3
FILE NO. : "' , S.S/D.C. NO. : ACN: 14148957
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: MEMBERS 1sT FCU ACCOUNT NO . : 12673-00
TYPE OF ACCOUNT: C ) SAVINGS C ) CHECKING ( X) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 11-04-1971
Account Balance •00 NOTE: TO ENSURE PROPER CREDIT TO YOUR
Percent Taxable X 0.500 ACCOUNT, SUBMIT THE UPPER PORTION
Amount Subject to Tax •00 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions - •00 PAYMENT TO THE REGISTER OF WILLS
Taxable Amount •00 AT THE ADDRESS SHOWN ABOVE.
Tax Rate X • 15 MAKE CHECK OR MONEY ORDER PAYABLE
Tax Due •00 TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER THIS DATE, SEE REVERSE 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.