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BUREAU OF INDIVIDUAL TAXES RECORD ADJUSTMENT DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION REV-1593 EX AFP (12-14)
PO BOX 280601
HARRISBURfi ftt 2L86R nFF!L !1 E VF
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ESTATE OF FORNEY RAY K
?�15 �+!!G 31 Fi m I 1 2 2)5 DATE OF DEATH 12-18-2013
` FILE NUMBER 21 14-0005
COUNTY CUMBERLAND
OR �F ACN 101
�(MNEY-�E�XECU DAVID L Amount Remitted
�+&L GATES LLP
1601 K ST NW MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
WASHINGTON DC 20006-1682
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 -1 RETAIN LOWER PORTION FOR YOUR RECORDS ----
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REV-1593 EX AFP (12-14) ** INHERITANCE TAX RECORD ADJUSTMENT **
ESTATE OF: FORNEY RAY K FILE NO. :21 14-0005 ACN: 101 DATE: 08-13-2015
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
VALUE OF ESTATE:
1. Real Estate (Schedule A) (1) 195,000.00
2. Stocks and Bonds (Schedule B) (2) .00
3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00
4. Mortgages/Notes Receivable (Schedule D) C4) .00
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 84,851 . 18
6. Jointly Owned Property (Schedule F) (6) .00
7. Transfers CSchedule G) (7) 25,437.53
8. Total Assets C8) 305,288.71
DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Administrative Costs/
Miscellaneous Expenses CSchedule H) (9) 36,948. 10
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 164,000.87
11. Total Deductions C11) 200,948.97
12. Net Value of Tax Return (12) 104,339.74
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00
14. Net Value of Estate Subject to Tax (14) 104,339.74
TAX:
15. Amount of Line 14 at Spousal rate C15) 00X.00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 104,339.74X.045= 4,695.29
17. Amount of Line 14 at Sibling rate (17) 00X. 12 - .00
18. Amount of Line 14 taxable at Collateral/Class B rate C1s) 00 v. 15 = 00
19. Principal Tax Due (19)
TAX CREDITS: 4,695.29
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
03-11-2014 CDO18884 115.79 2,200.00
08-11-2014 CDO19521 .00 2,047.79
12-15-2014 CD020036 2.39- 337.50
05-20-2015 REFUND .00 343.29-
INTEREST IS CHARGED THROUGH 08-28-2015* TOTAL TAX PAYMENT 4,355.40
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 339.89
REVERSE SIDE OF THIS FORM INTEREST AND PEN. 2.79
TOTAL DUE 342.68
* IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE `
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. \
REV-1470 EX(01-10)
pennsytvania INHERITANCE TAX SSN:
,= DEPARTMENT OF REVENUE EXPLANATION
BUREAU OF INDIVIDUAL TAXES OF CHANGES DOD: 12/18/2013
PO Box 280601
HARRISBURG, 17128-0601
DECEDENT'S NAME FILE NUMBER
Ray K. Forney 2114-0005
REVIEWED BY ACN
James (Agent 197) 101
ITEM
SCHEDULE NO, EXPLANATION OF CHANGES
Deductions in the amount of$7,500 for personal representative commissions for Mr. David
Forney have been removed from Schedule H.
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