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RCC- 3 (1-691
APPLICATION FOR CHARITABLE EXEMPTION
FROM PENNSYLVANIA TRANSFER INHERITANCE TAX
(Act of May 28, 1956, P.L. 1757, and Act of June 15, 1961,
P.L. 373, as amended)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
Application is hereby filed for the approval
of an exemption from Pennsylvania Transfer
Inheritance Tax on the transfer of the property
described below:
1. Bureau File #
21-78-0047
January
}J'I.
. . .
13, 1978
2. Date of Death
3. Date of Approval
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4. Name of Decedent
Sara C. Barclay
5. The Commonwealth's appraised value of the property for which an exemption is claimed is $ 200.00
(Note: Where the property is other than a specified amount of cash, the exemption cannot be approved until the value of
the property has been established by appraisal by the Commonwealth, except in those cases where the amount of the gift
or bequest represents a stated fractional or percentage portion of the entire estate or the entire residue. In those cases
enter such fractional or percentag.e amount above).
6. Check the manner in which the transfer was effected and submit a copy of the document authorizing the transfer, unless
such material has been previously filed.
WILL '5;
DEED 0;
TRUST INDENTURE OJ
SURVIVORSHIP OJ
OTHER 0;
(If other, explain)
7. Correct Business Name and Address of Charitable Organization receiving property:
Grace United Methodist Church
NAME
ADDRESS Car1is Ie, Pa.
17013
8. I certify that the information contained herein is, to the best of my knowledge and belief, true and correct.
Address of Applicant
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Signature of Appl icant
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Executrices
Official Title
Date
July /7, 1978
This form must be completed in triplicate and all three copies delivered to the Register of Wills for the County in which the decedent
resided, or in which letters were issued for a non-resident decedent's estate. If the decedent was a non-resident of Pennsylvania and
letters were not issued by a Pennsylvania Register of Wills, deliver all three copies to the Director, Bureau of County Collections,
Penna. Department of Revenue, 26 S. 4th Street, Harri sburg, Pa.
Do not write below this line. For Official Use Only
Approved: For the Secretary of Revenue
Referred to Bureau Headquarters
Approved 0
For Secretary of Revenue
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(Sign~~ure.~f..=-R~~~,~.~~ of Wi II str~.J-
:;":: Of VilU.S
(Cou~iyj 'J;.:C/1 ') 19'),\
(Date of Approval) ,
Denied* 0
(Initials of Register of Wills)
(Authori zed Si gnature)
(County)
(Title)
(Date of Referral)
(Date of Action)
* See reverse side for reasons
MUST BE FILED IN TRIPLICATE