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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 STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601 RE-CORDED OFFICE OF
REGISTER L,F 'A*q 09-14-2015
,S
ESTATE OF FORNEY RAY K
MIS SO 29 pj�It
?�E�BF DEATH 12-18-2013
FILE NUMBER 21 14-0005
FORNEY EXECU DAVID L CI-Ei"� OFCOUNTY CUMBERLAND
ORPI-Imls, CgtACN 101
K&L GATES LLPAmount Remitted
1601 K ST NW CUMBERI-Atlf) —
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 PORTION FOR YOUR RECORDS !—
REV-1607
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- TAX STATEMENT l)� i6ciobif
EX C12-14) INHERITANCE:
ESTATE OF:FORNEY RAY K FILE NO. : 21 14-0009 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
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.