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BUREAU OF INDIVIDUAL~n;:f) ('\CC:r:E rF
INHERITANCE TAX DIVISION n~l,-, '-- lJ_t I 'V_.., -'
PO BOX 280601 ,. ;" - - t, '.:- I'~
HARRISBURG PA 17128-0601-
COMMONWEALTH O~ PENNSYLVANIA
DEPAR'MENT OF REVENUE
INl'lERITANCE TAX
REC~RD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
*'
REV-1604 EX AFP (03-05)
2005 tUG 30 P;>1 '1: 24
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
08-18-2005
SMITH
08-22-2004
70 0333136
CUMBERLAND
292-14-4343
04143946
HANNAH 0
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f"'C::-'_ '
1_-1
EUGENE C~cSMITH
509 B SOUTHWEST ST
CARLISLE PA 17013
Allount R..itt.d
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
-
REV-1604 EX AFP (03-05)
__ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS __
DATE 08-18-2005
ESTATE OF SMITH
HANNAH
o DATE OF DEATH 08-22-2004
COUNTY
CUMBERLAND
FILE NO. 70 0333136
ADJUSTMENT BASED ON:
S.S/D.C. NO. 292-14-4343
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
ACN
04143946
FINANCIAL INSTITUTION: oRRSToWN BANK
ACCOUNT NO. 106001704
TYPE OF ACCOUNT: () SAVINGS (X) CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 10-23-2000
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
2,165.10
0.500
1,082.55
1,082.55
.00
.15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE nn
. IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRN FOR INSTRUCTIONS.)
~
REV-147QEX (&-a8)
'*' INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS N1AME FILE NUMBER
Hannah Smith 700333136
REVIEWED BY ACN
Emerson Luciano 04143946
SCHEDULE ITEM EXPLANATION OF CHANGES
NO.
Funeral deductions totaling $1,082.55 have been accepted.
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