HomeMy WebLinkAbout02-22-10,~.~ REV-485 EX (05-04)
SAFE DEPOSIT .,
BOX INVENTORY
PA Department of Revenue
48500041,046
PLEASE USE ORIGINAL FORM ONLY
Social Security or Death Certificate Number Date of Death County Code Year File Number
Decedent's Last Name Suffix First Name Mi
ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE:
NAME AND ADDRESS OF PERSON QUESTING THE OP NING OF THE SAFE DEPOSIT BOX
NAME: S"" ' y C~/Y G---. .~.,~
STREET ADDRESS: ' / CITY: STATE: ZIP CODE:
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO CEDENT, OF PERSON(S) PRE AT THE BOX OPENING
a. NAME: RELATIONSHIP: ,v
STREET ADDRESS: , CITY: STATE: ZIP CODE:
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b. NAME: ~~ LATIONSHIP: a
STREET ADDRESS: ~ ~ ~
'~~~ CITY:
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~ STATE: ZIP CODE:
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c. NAME: ~ / ,---~-.~-- RELATIONS ~P_:~ ~i ,,~
STREET AD ES • - CITY: / STATE: ZIP CODE:
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT OX IS LOCATED
NAME ~ ~~~~
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STREET D RESS: CITY: STATE: ZIP CODE:
NAME OF PERSON MAKING LAST ENTRY ~~?~ DATE AND
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~ E OF LAST ENTRY
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~°v'G~Y ~ ~~.~ ~ E~i . ,C7' / ,..?"
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Dy~E OF CONTRACT TO RENT BOX NUMB, E/ OF B X 1 TITL/E UNDER WHBICH BOX IS RE UESTED
NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX fj-y~ ~' , ~~
a. NAME:?
~Ci L~%'l Y ~• ~G-~i~' b. NAME:
STREET ADDRESS• ~/ _ STREET ADDRESS:
CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE:
NAME AND TITLE OF EMPL EE TAKING THE INVENTORY ....,.
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WAS A WILL IN THE BOX? ^ YES ~NO If yes, a. Date of will f~,.f:_~ -~ ~ :; , '
b. Name and address of personal representative, if named in the will ~.~- _
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NAME: t a
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STREET ADDRESS: CITY: '5~ Z ODE:- -~
c. Name and address of attorney, if any _ W r ; y ~,
NAME: ~
STREET ADDRESS: CITY: STATE: ZIP CODE:
L 4850D041~46
48500041046
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REV 485 EX SAFE DEPOSIT B
INSTRUCTIONS OX INVENTORY Page-of~
(~) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other ri ht
name of company, certificate number, date of certificate, name in which stock is registered, and
g s found in box. Stocks are to be designated by
(3) Obligations of U.S. Government: Number of items, date of issue, face value na number of shares and class of stock.
i.e., jointly held, payable on death, etc. mes in which registered and type of ownership,
(4) Bonds: Designate by name, amount, serial number, or other designation. Bearer
(5) Bank and Savings and Loan Passbooks; State name of depositor, number of b Bonds)
and branch, and balance. ook, last date a
(s) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as full as ppearing in book, name of bank
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebbee
(8) All other contents. dness: List and describe as fully as possible.
(9) Return completed form to:
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
ITEM HARRISBURG, PA 17128-0601
NO.
ITEM DESCRIPTION
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I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD I
CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF
SIGNATU _
PERSON RECEIVING COPY OF
.
,~~ ~ - •~ ~
~" SAFE DEPOSIT
BOX INVENTORY:
SI ATURE
PRINT NAbtE /
~--.J/ - ,~/~`'~/fy
°~ ~~'~L
~
NAME AND CHECK APPR PRIATE BO B
PRINT TITL
'
DATE
• .~C'/2"G'-Gy' `-~L. ~°~~~,[5Y/ ~
/ ~-~/ ~~~
/ ~1~'`
CHECK APPROPRIATE BOX:
~~~~~ ~ecutor trix
~ ) ^ Administrator trix
NOTE: Attach additional 8'/x"
x 11" sheet(s) if necessary or use
The Department is authorized by law
42 U
S
C ^ Estate Representative ~ Joint owner of safe deposit box
duplicate
,
.
.
s of this page of form.
. §405 (c)(2)(C)(i), to require disclosure of Social Securi numb
Social Security number to identify the decedent and personal representatives of the estate. The Commonweal
ty ers in connection with administering state tax laws. The Department uses th
with Federal and local taxing authorities. The state law prohibits th
th may also u
C
th
e
e
se
ommonwealth's personnel fr
e information in exchange of tax information agreements
om disclosing confidential tax information except for official purposes.