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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES , INHERITANCE TAX REV-1607 EX AFP C12-14)
INHERITANCE TAX DIVISION
PO BOX 280601 STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601 f\C C O IRD E D OFFICE O f-
R E 0)15 T!�.' Vit_ IN11-LS DATE 09-14-2015
ESTATE OF FORNEY RAY K
?015 Sp 2 L P11 12 58 DATE OF DEATH 12-18-2013
FILE NUMBER 21 14-0005
FORNEY EXECU DAVID L CLCt. , (ClF COUNTY CUMBERLAND
K&L GATES LLP ORI HE:H')' C !'J'!" ACN 101
1601 K ST NW CUMBE?LtI ND ry ;`+ Amount Remitted
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 P_ORTI_ON FOR YOUR RECORDS _ � _ _ _ _ _ _ _ _ _ _ _ _ _ _
REV-1607 EX AFP C12-14) *** INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF:FORNEY RAY K FILE NO. : 21 14-0005 ACN: 101 DATE: 09-14-2015
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: 08-12-2015
PRINCIPAL TAX DUE: 4,695.29
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
*** SUMMARY OF ALL 006 PAYMENTS ***
09-11-2015 115.79 .00
09-11-2015 5. 18- 4,584.76
TOTAL TAX PAYMENT 4,695.29
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. \J\