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REwres EX .1~1
SAFE DEPOSIT BOX
C~DEPARTMENT OF REVENUE~IA INVENTORY
INHERITANCE TAX DNISION
DEPT. 280601
HARRISBURG, PA 1Tt28-0601
Please riot or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND R R NLD TO ABOVE ADDRESS
COUNTY CODE FlL.E NUMBER SOCW. SECUFt17Y Iftsqui-sd) OR DEATH (:ERTFICA NUMBER lonh H SSN k wNu~oanl
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DE DENTS NAME (LAST FIRST, MIDDLE) DATE OF DEATH
u.ci er ! e o S -~- O
ADDRESS OF DE ENT (STREET)
O ~ e.w 4Zcl (CITY) (
N e-w v i+ l ATE)
~ (ZIP CODE)
i day 1
NAME AND ADDRE8S OF PERSON REQUESTING THE OPENING OF THE_8AFE DEPOSIT BOX
(NAME) .
(STREET E) (CITY) (S ATE') (ZIP CODE)
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NAME, ADDRESS AND RELATIONSH~ (IF ANY) TO DECEDENT, OF PERSON(8) PRESENT AT THE BOX OPENING
a. (NAME) (RELATIONSHIP) '
t~
(STREET NAME) (CITY) Q (S ATE) ~ (ZIP CQD~ y
b. (NAME)
(RELATIONSHIP) ~} `~-' : -_
~ t . _, ti ~~
N
(STREET NAME) (CITY) ) (ZIP ~ }-
"
Q~ ~
-~
e. (NAME) (RELATIONSHIP) C -, :-=)
{STREET NAME) (CITY) {S TE) 6•~ (ZIP , ~
C.'1
NAME AND ADDRESS OF FNVANCIAL IN8TITUTION WHERE THE 8AFE DEP08R BOX 18 LOCATED
M-r-hr~ Trust- Ca
(STREET NAME) (CITY) . (S TE) (ZIP CODE) ''
1 NAME OF PERSON MAKING TEN DATE AND TMIE OF LAST ENTRY ,
DATE OF C CT TO RENT BOX NUMBER OF BOX ~ TRLE UNDER WHICH BOX I8 REQUEBTED
- I -q -- 2 e~- I e o ~-'
NAME AND ADDRE8S OF PERSON(8) HAVING ACCESS TO BOX
a. (NAME)
m~ ~ ~ ~~d~-- b. (NAME)
c~ n ~c 4 ~~ ~
, ~
~-
( ~ l~ ~~i)h.1~ ~ e~ » ,
'~A (STREET DRESS)
a ekv- ~w Rd !
(CITY) (STATE)
Q,W v1 I1 Z Ppt (ZIP CODE)
l 1 i (CITY) (
2,w v~l r1e ,~ S ATff) (ZIP CODE)
t~ ac j/
• NA
ME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
I
a
rT-'~d,1--ea_ ~ - ~id e-Y' - ~/u.S'f°~-•-,~- scrvlce !Q rese i ve Tr~.
WAS A WILL IN THE BOX? ^ YES O N yes, a. Dsb of wIY:
b. Name and sddrass of personal ropresentatNe, N named in the will
(NAME)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
c. Name snd address of attorney, N any
(NAME)
(STREET NAME) (CITY) (ST ) (ZIP CODE)
SAFE VFENTQR'1r Page~Df ~-
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INSTRUCTIONS
The Department is authorized under federal law , 42 U.S.C. § 405(c), to use the decedent's Socal Security number in
adrrNnistering this state tax taw. The Department uses Social Security numbers to establish a decedeM's identity and
ensure proper credit for tax payments.
(1} Cash;. Report total oMy.
(2) Stocks: List in detail every common or prefaRed certificate, wa+rant or other rights found in box. Stocks are to be
designated by name of cornipariy, Certificate number, date of certificate, name in which stock is registered, and
number of shares and class of stock.
(3} Obligatlions of U.S. Government: Number of items, date of issue, face value, names in which registered and
type of ownership, i.e., jointly held, payable on death, etc.
(4} Bonds: Designate by name, amount, serial number or other designation. (Bearer Bonds)
(5} Bank and Savings and Loan Passbooks; State name of depositor, number of book, last date appearing in book,
name of bank and branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully
as possible.
(8} Ali other contents.
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I CERTIFY uNDglt PEN~rr or: PERNlRY rw-r 7'ME ~sovE RECORD IS
C CT ANO C TO TFiE 6E
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ARY
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WO~YYI.EDpE AND BEt.~F PERSON RECEfVING COPY OF
SAFE DEPOSR BOX INVENTORY:
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TURF ~~%'~.,/ t~1./~tG.^ SIGMA RE
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r . ~' ~ ~ PRINT NAME D CHECK APPROPRIATE BOX BELOW:
d (.. eab,.:d
PRINT TITLE
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1'l~-(J~ ~ C..t 1 ~ DATE
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- (u CHECKA OPRIATEBOX:
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~Exettdot(trix) Admitietretor(trix}
~ Estate RepreaeMatiw [] Jant owner of eats dePoeil box
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nv I c: iaaacn aaaraonal a•~s__ x ~i° sneer(s) ff necessary or use duplicates of this page of form.