HomeMy WebLinkAbout81-00504
COMMONWeAl TH OF PENNSY~VMlI"
oePARTMeNT OF ReveNue
BUREAU OF COUNTY co~~eCTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
'*
~ (MUST BE FilED IN TRIPLICATE)
TO THE PENNSYI.VANIA Def:lARTMENT OF REVENUEI '
Applloallon Ie .h,r.by mod, for conlent to th. tronlf.r of the following .eourltl.. of aP,nn'ylvanla
Corporation or a Nallonal Banklnv Anaclatlon looat.d In Pennlylvonlal, , '
(aLa ,b,"' (b)llS... aoll~t~ tlja1d.ClAU DaRk (0) ,C_n
(NOTEI In d..crlblng ..ovrltl.. ,nter In (a), a~ IN" olthor .the numb.r of shar.. of stock or th, foe, amount of
reglltered bond., In (b), the name afth, Inulng oompdny and In (e) the clan of Itook or the .tated Interut rate
and maturity ,date of !tgl...,.d bandl.)
ISSUED ON ~y:a.h J."O ,and h9vlng a TOTAL MARKeT VA'Lue OF $ .QO.OO
,(Do,.) " '
aaoflh. date of death oflhe .d.eed,nt,. ~.~, 11. Otal&b ',an M4v 1. un
(Homo of Dooo~ont) (Doto of ~ooth)
DATE A~wu."" ,),4, ,l.Ul
who was late of U '..lIIf~1t p~u... .Cllu'll~d.burCi
('Hoot ~nd H~m~OI) (POIt 0/1100)
o".htt,laail
(CO"",V)
fA
($toto)
The '''ourltl.. ate regllter.d. oe followlI
r..U.:.r .:I, ~U;..ub
(Homo 0' nom.. In whloh ..1\11100'" ot."gl.,."d)
ADMINISTRA TORl
eXECUTOR
(Add"..)
NAME OF AP~I.ICANT Xa'hl'Y~j\i BU~
COUNTY FILE NVMBI!R .... AQQRE~S OF APPLICANT U KelUQOk.OX','. M~Qh~tl'brtn,
BUREAU FILe NUMBeR . .... SIGNATURE OF APPl.ICANT'~i!r!r'J'-l}.j!laf' ;/-
MOTIClh Ir yOU r~lI. T.O PROPIlR\.YPI~,~ 1M AMY PORTIOMOP THIS APP\.I\:ATI. ,'IT WI\.\. MOT.PI
COMSlDIlRIlD e,OMP\'1lT1I AMP WI\.\. BE RBTURMIID TO YOU POR COMP\.BTIOt'l.. ,
,
COMMONWEALTH OF peNNSY.l.VANIA - DePARTMENT OPREVEHUE
CONSENT TO TRANSFER .seCURITIES ' ,
, DATE
Ih.!tby conlOn.' to the t'ran.f"r9f the abaye aecurlll.. nowrogllterod In the .name of the of
MOD.
(Homo)
D.ced'Mand walv, the II ling of .a. cerUflcate cerllfylng to tho payment of thot.ran.fet Inherllance tak to wh.leh
the property al.ald D,cedentl' load, .ubl.ct purluan't to the .provlelon' of the Act of June 20, 1919, P.l. 521,
albm'nd.~ and th, Act af Ju.nt 15,1961, P.l.. 373, a.amended. This II alebln accordance wll~ th, provisions
af th. Aot of April 9, 1929, P.l.. 343.
'thleCa~,ht ta 'transl'; Ihe h'telnducrlb.d properly operetta ~nly In, r,ltt.nbet~ thet~tQIO ~f .the'
abov..nam.d D'Qld.nt.
'. By
.;lJ, fI ...,,:;{) f
.
INSTRUCTION'
AnBT' _ P.lCrlb. 011 R..l Iltal. lacct.d In Penneylyanl,'and h.ld eol.ly br d.c.d.nt or h.ld lalnlly with ,nalh" parly
"partlee n I,nanh In c,lTI11an or ae lolnt I.nanh with rlghl 01 lurylyotlhlp. nclud. th, d.ced.nl'e p.rcentag. ,Iawnerlhlp
ond Ih. "tlmat.d mark.t y,lu.. Llel allt,nglbl. and Intanglbl.pmonal prap"ty awn.d Indlyldu,lly by the d.ec,d.n.t or
lolnlly with anoth.r r'rtr tf portl" at lolnt I.nanh with rlghl of IUrY,lyorthlP ,ot Iht tlm. of d.ath. Includ.lnt,nglbl.
p.tlon,1 properly tit ed nlh. n,m.of Ihed.Qtdenl, but payabl. at d.ath to another party or partl.. Including bul notllmlt.d
10 P.O.P. U.S. hYlnge Bonde and ttntotlY. trutl accountl. 1.1 tI any plllperly traneferr.d by th. d.c,d.nt, within two y.a,.
of d..lh for whl.ch h'/Ihe did nal reClIY. valuable and ,d.quat. caneldtratl,n.' '
pun a. PBPU!:TION$.. Un~atl.fl.d lIabllitl" Incurr.d by Ih. d.c.d.nt prior to hie/her d.ath 0" dtducllbl. agoln"
hie/her to~,bl. ..tat.. In ,~dltlon to d.bh Incurred by the d.c,d.nt, ~ther ittme art clolm,bl. Including Ih. call of
,dmlnletrallon, atltfney I,u, Ilduclary Ie.., luoeroland burial '~p.ne" Including the 0011 01 0 burl,llof, t,mbelon.or
~~m~~ . . ..' . '. '
Ivld.nc. I' eupptftth. d.ced.nt'e or the hl,It'.II,blllty for Ihe d.bh ~.In, clalm,d .hould b. otl,ch.d to Ihll r.lutn,
A family e~tmptlon of $2,000.00 moy b. clalm.d by a epoult of, d.ctd.nt who died domlclltd In P'nn.ylvanlo. II Iher.
Ie no epOUI" or II tht .p,UIt hat forf,lt.d hlelh.r rlghU, Ihtnany child oltht d.ctdtnt who Ie m.mber 01 the 10m. houuhald
con claim Ihe eM'. mpllan. In Ih. ev.nl\,.Iher. II no euch IP,UIt or ohlld,tht ,~.mptlon can b. claimed by , parent ,r par.nh
who art m.mbtre ,I Ih. ..me h,u ..h, d at the dtc.d.nt. '
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e.llAC~. FOR FILIl'lO _ 'the return Ie to .b. flltd In duplicate with tho R.glel" 01 WillI of Ih. covntywher'ln tho,d.c.d.nt
,,,1 ded, ' '
1JMUg~ FI"I~9 ~lh. r.turn II due nln.manthe aholth. d.ced"nt'I'd.alh, unl... an '.~"nelon lar,flllnG hoe bun
appll.d lor ond grant.d by Ih. hcr.tary 01 R.v.nut wlthlnth, nln..moMh pOllod. ,
l!.MbJ.I.B.t 'to PI~B RtlT.l.UiN _ hCllan 79101 Ih.1961 Stutl"e provld.1 thaI".) . .,ny penon who willlully lalh}olll,.
o retul1l or olher repatt required alhlm eholl bo ptllonally Ilabl. . . .1, apen,lty of 28% 01 Ihe taMulllmat.ly found
to be due or $',000 whlch.v" Ie tho 1....10 bo rtcovor.d by Ih. O,pattmtnt 01 Rey.nu. Ol d.bh 01 Ilk, omount ore
leooverable by 1,011"'" ,.
lNf:Q!l.M8llil~. \'
To In8uro propor orod.11 10 your OCOOUIII, Iho I\Omo of Iho O.IUID nnd 1110 numbor .hould bo clonrly prim,
od on Iho ohoek or monoy ord.r.
Thl. 81ao88mont I. made In eccordnnon wllh aoollon 708 of 1110 Inhorlloncll ond a810to To. AOI of
I Bel 172 P,8, D 2486,7081,
To tho o.lo,;t thot Inhorllonoo 10. 18 p.ld wllhln lIuoo (3) monlh8 nftor Iho doolh 01 Iho d.codenl, 0
dl.oounl of IIvn 161 poroonl18 ollowod (72 P;8, 9 2486.7101,
Inhorllonoo To'. othor Ihon to. on . fUluro Inlor08t, I. duo ot Iho dole of Ihe dooodonl'8 doolh and booom08
dollnquonl 01 11'0 o.plr.llon 01 nino (B) monlh8 ollor Iho dooodonl'8 dOOlh 172 I>,a, 9 2486.711). InllOrllonoo
To. on 0 fUturo Inlor081 18 p.yoblo within throo (31 monlh8 oftor Iho Iron8for lok08 011001 in P08,0..lon and
enjoymont end 18 dollnquonllhoroollilr 172 P,S. 9 2486,7121, ealoulolo Inlor081 from Iho dollnquont dolO el10wn
on tho foo. of thl8 form to tho do to of ootuol poymont u8ing tho follOWing Inl.roellal>l.:
...--......---.....-- --------- --...................-....-... ,~,,,,- - - - .....,.....,.---..... ~ - -,..- - --.... --...;-....---....- ...- ~.- - -... --
, month ,006 4 month. ,020 7 monll'8 ,036 10 ,"onUt. ,060
2 month. .0\0 6 month8 .028 8 mohth8 ,040 I I month8 ,066
3 month8 ,016 6 mOnth8 ,030 9 mMlhe ,046 12 monlh8 ,060
, , dOY8 ,00017 I I dOY8 ,00166 21 doys ,00362
2 <foy' ,00034 1'2 doye ,00203 22 doye ,00389
.. 3 <foya .00061 13 dOY8 ,00220 23 doya ,00386
4 doya ,00008 14 dove ,00237 24 days ,00403
6 dey, , ,.00088 1 t dove ,00280 26 doya ,00420
e day. ,00101 1 doys ,00207 2e d.y. ,00437
7 dsya ,0011e 17 doy. ,00284 27 daY8 ,00484
8 day, ,00138 16 doY8 ,003<)1 28 dov. ,00471
Bdoya ;00162 19 doyo ,ooa18 28 doy. ,00488
,6 doy' ,00109 20 dOY8 ,00338 30 days ,00600
...... ---------...--_...._---- --.... -............. - -...- -- -- -........- --... .......-.--........ - -..... - "'-.---"'.-- .............-..
Any. p.rty' In Intore8l, Inoludlng Iho eommcnwoollh ond tho porsonol roprosontallvo, nol 80U.llod wllh
tho o8881Smel1t moy ob)oOI thorolo within .I.ty 160) dOV8 utllir rooelplof Ihls Nolloo .. provided by Saollon
1001 of U,e Inhorll.noo ond altote Ta. Aot of 1ge1 172 I>,a, ~ 2488,\001,1
Ma~,o clleck or monayorder pnyoblo,IO:
"Register of Wills, Agent"
Moll 10 the address listed below: