HomeMy WebLinkAbout11-07-14 1505610105
REV-1500 EX(02-11)(FI)FI!II
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes .......... ""E�E��E County Code Year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT L OU
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY
02/19/2014 10/26/1923
Decedent's Last Name Suffix Decedent's First Name MI
r
Bennett j 'Gertrude ( j B
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
C@D 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
C=) 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
CID 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
,Richard J. Seneca, Esq. (717)932-6000
REGISi:ERWILLS U�ONLYrI
First Line of Address -�
c ~; r1 .3 m t
P.O. Box 333 '
Second Line of Address c� cl `� 'I
- _.I
680 Yorktown Road
City or Post Office State ZIP Code DATE FILEDr, r—
Lewisberry PA 17339 0
Correspondent's e-mail address:rjseneca@senecalaw.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
ATURE OF P RSON PONSIBLE FOR FILING RETURN DATE
ADDRESS
1575 Valley Road, Etters, PA 17319
SI EP E ER THAN REPRESENTATIVE DATE
ADDRESS
Seneca Law, .0. Box 333, 680 Yorktown Road, Lewisberry, PA 17339
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Gertrude B. Bennett j
RECAPITULATION
1. Real Estate(Schedule A). .......................... .................. 1. 0.00
2. Stocks and Bonds(Schedule B) 2. 0.00
.......................................
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable Schedule D 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 69,178.17
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 0.00
8. Total Gross Assets total Lines 1 through 7 8. 69,178.17
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 7,206.86
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............... 10. 18,163.95
11. Total Deductions(total Lines 9 and 10)................................. 11. 25,370.81 .
12. Net Value of Estate(Line 8 minus Line 11) ............ .................. 12. 43,807.36
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ....................... . 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. . 43,807.36
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate x.045 43,807.36 16.. 1,971.34
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 ! 18.
19. TAX DUE ......................................................... 19. 1,971.34
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT < 1
Side 2
L 1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Gertrude B. Bennett
STREET ADDRESS
100 Mt. Allen Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 1,971.34
2. Credits/Payments
A.Prior Payments 3,150.00
B.Discount 98.56
Total Credits(A+B) (2) 3,248.56
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 1,277.22
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
1111111
a. retain the use or income of the property transferred.......................................................................................... [__1b. retain the right to designate who shall use the property transferred or its income ............................................ El 0
c. retain a reversionary interest .............................................................................................................................. El0
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ N
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ E
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
containsa beneficiary designation? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-15o8 EA(o8-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Gertrude B. Bennett 2014-00258
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members 1st Federal Credit Union Regular Savings Account(See attached date of death value sheet.) 38.65
2 Members 1st Federal Credit Union Investment Savings Account(See attached date of death value sheet.) 61,466.21
3 Santander Checking Account(See attached date of death value letter.) 7,573.31
4 Miscellaneous Personal Property 100.00
TOTAL(Also enter on Line 5, Recapitulation) $ 69,178.17
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(08-13)
i 'Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gertrude B. Bennett 2014-00258
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Parthemore Funeral Home&Cremation Services,Inc. 86.16
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 3,450.00
Name(s)of Personal Representative(s) Donna J. Good
Street Address 1575 Valley Road
city Etters State PA zip 17319
Year(s)Commission Paid: 2014
3,200.00.
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 233.50
5. Accountant Fees: 0.00
6. Tax Return Preparer Fees: 0.00
7. Estate Publication Fee-Cumberland Law Journal. 75.00
8. Estate Publiation Fee-Central Penn Business Journal(Journal Publications). 150.00
9. Postage. 12.20
TOTAL(Also enter on Line 9, Recapitulation) $ 7,206.86
If more space is needed,use additional sheets of paper of the same size.
REV-1512 Ek+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,.
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gertrude B. Bennett 2014-00258
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH.
1 Alert Pharmacy Invoice Balance Due. ~~ 33.65
P2� U.S.Department of Veterans Affairs Overpayment Refund. 1,538.75
3 Macy's,Inc.Pension Plan Refund. 114.95
4. Messiah Lifeways Invoice Balance Due. 16,035.60
5. 2013 Personal Income Tax Payment(Advanced by Donna Good). 441.00
tzl
E I
El
.1 4mlf
'-.�_.__..____ ___.._______:__-_� �.z---r��--Yom•-- _._ �i�-�^
TOTAL(Also enter on Line 10, Recapitulation) $ 18,163.95,
If more space is needed,insert additional sheets of the same size.
REV-'1513 EX+'(01-10)
pennsylvania SCHEDULE J
I DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Gertrude B. Bennett 2014-00258
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).)
I. Donna J.Good Daughter 80%
2. Robert W.Good Grandson 20%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
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-11 '17
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GERTRUDE B. BENNETT
rcr
N Cf) G
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I, GERTRUDE B. BENNETT, of 201 Old York Road,
Apartment 2, New Cumberland, Cumberland County, Pennsylvania,
being of sound and disposing mind and memory, do hereby make,
publish and declare this for and as my. Last Will and Testament
hereby revoking any and all Wills by me at any time heretofore
made.
ITEM I - I direct my Executrix, hereinafter named, to
pay all my just and lawful debts and funaral expenses out of my
personal estate as soon after my decease as is convenient.
ITEM II - I give and bequeath all of my personal effects
ects
and household furnishings to my daughter, DONNA J.GOOD.
ITEM III I give and bequeath the sum of $1, 000.000 to
St. Matthew's Lutheran Church, Harrisburg, Pennsylvania, if St.
Matthew's is in existence and holding regular worship services at
the time of my death.
ITEM IV - All the rest, residue and remainder of my
estate real, personal and mixed I give, devise and bequeath, as
follows:
to my daughter DONNA J. GOOD _ 80%
to my grandson, ROBERT Wo GOOD _ 20%.
ITEM V - My Executrix shall have the following powers
for the administration of my estate except as limited hereinabove,
in addition to those vested in her by law and by other provisions
of my Will:
A. To retain any or all assets of my
estate, real or personal, without regard to
any principle of diversification, risk, or
productivity,
Bo To invest in all forms of property
including stocks, common trust funds and
mortgage investment funds, without
restriction to investments authorized for
Pennsylvania fiduciaries as she deems
proper, without regard to any principle of
diversification, risk, or productivity.
J
2
4
i
C. To sell at public or private sale,
to exchange or to lease, for any period of
time, any real or personal property and to
give options for sales, exchanges or leases,
for such prices and upon such terms and
conditions as she deems proper.
Do To borrow money from any person
or institution including my Executrix, and
to mortgage or pledge any or all real or
personal property as my Executrix in her
sole discretion, shall choose, without
regard for the dispositive provisions of
> this instrument.
E. To compromise any claim or
controversy.
Fa To exercise any option, right or
privilege granted in insurance policies or
in other investments.
ITEM VI m All federal, state and other death taxes
payable because of my death, with respect to the property forming
my gross estate for tax purposes, whether or not passing under
this Will, including any interest or penalty imposed in connection
3
With such tax, shall be considered part of the expense of the
administration of my estate and shall be paid from my estate
Without apportionment or right of reimbursement. All such taxes
on present or future interests shall be paid at such time or times
as my Executrix, may think proper, regardless of Whether such
taxes are then due.
ITEM VII - I appoint my daughter, DONNA J. GOOD, to be
the Executrix of this my Last Will and Testament.
ITEM VIII - I direct. my Executrix be allowed to qualify
and serve as such Without the posting of any bonds
ITEM X m I direct my Executrix to retain the services
of Rupp and Meikle for the settlement of my Estate, if such
services are available, because of their familiarity With my
affairs.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
'aa day of July, 1989
:�� .�:. ; ,f� %' z�• SEAL
:: ,:" (SEAL)
GERTRUDE B.' BENNETT
Witnesbes
residing at .,.j �.. .� ,� ,gu._.
•�� ;�:. ,' s'a' fJ' residing at
COMNONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF
I, GEWRUDE B. BENNETT, testatrix, whose name is signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my Last Will; that 'I signed willingly; and that
I signed it as my free and voluntary act for the purposes therein
expressed.
Sworn or affirmed to and acknowledged before me by GERTRUDE
B. BENNETT, testatrix, this j day of July, 1989.
ONotary Public
Ky
UPPER ALLEN I WP.' CUMBERMT.1,CPA.
COMMONWEALTH OF PENNSYLVANIA MY COMMISSION EXPIRES APR. 2, 1992
COUNTY OF
We, and
the witnesses whose name'./are signed to the 'attaq#bd or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the testatrix., GERTRUDE B.
BENNETT, sign and execute the instrument as her Last Will; that
she signed willingly and that she executed it as her free and
voluntary act for the purposes therein expressed; that each of us
in the hearing and sight of the testatrix, GERTRUDE B. BENNETT,
signed the Will as witnesses; and that to the best of our
knowledge the testatrix, GERTRUDE B. BENNETT, was at the time 18
or more years of age, of sound mind and under no constraint or
undue influence.
Sworn to and subscribed FY
before me this day
of July, 1989.
V/-
NdLary Public
My commission Expires:
ISE
-] 1�� NOTARIAL SEAL
1 1 INIA U. CURTIS, NOTARY PUBLIC
!'PPER ALLEN IVIR, CUMBERLAND CO., PA.
My COMKIHSS1011'�l EXPIRES APR. 2, 1992
EMBERS V
ainREGULAR SAVING§ACCOUNT:
Account Number/Suffix 251576-00
Date Account Established 09/2712004
Principal Balance at Date of Death $38.65
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $38.65
Name of Joint Owner None
INVESTMENT SAVINGS ACCOUNT:
Account Number/Suffix 261676-05
Date Account Established 01/3112005
Principal Balance at Date of Death $61,460.15
Accrued Interest to Date of Death $6.06
Total Principal and Accrued Interest $61,466.21
Name of Joint Owner None
MEMBERS I sT FEDERAL CREDIT UNION
Tessa L Klugh
Lending Insurance Support Specialist
April 11, 2014
Estate of: GERTRUDE B BENNETT
Date of Death-, 02/19/2014
Social Security Number: 196-14.1542
5000 Louise Drive EO.Box 40 Mechanicsburg,Pennsylvania 17055 (800)283-2328 www.mcmberslst.org
Aril 24th, 2014
Attn: Richard J Seneca, Esq.
Seneca Law
P.O. Box 333
Lewisberry, PA 17339
Dear Mr.Seneca,
I am writing to inform you of the date of death value of Ms. Bennett's checking account,Account
number 0771028881.The amount which was in her account at the date of death, February 19,2014 was
$7,573.31.
If further information is needed please feel free to reach out to me.
Matthew Novosel
Personal Banking Representative
Newberry Commons
36 Robinhood Dr.
Etters PA, 17319
Tel.717-938-5900
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX0 1-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG,PA 17128A801
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 019167
GOOD DONNA J
1575 VALLEY ROAD
ETTERS, PA 17319
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- ftld ---------- -------
101 $3,150.00
ESTATE INFORMATION: SSN:
FILE NUMBER: 2114-0258
DECEDENT NAME: BENNETT GERTRUDE B
DATE OF PAYMENT, 05/15/2014
POSTMARK DATE: 05/15/2014
COUNTY: CUMBERLAND
DATE OF DEATH: 02/19/2014
TOTAL AMOUNT PAID: $3,150.00
REMARKS: RECEIPT TO ATTY
CHECK# 11001
INITIALS: DMB
SEAL RECEIVED BY: LISA M. GRAYSON, ESQ.
REGISTER OF WILLS
REGISTER OF WILLS
REV-485 EX(05-04) 48500041046
SAFE DEPOSIT 4&
BOX INVENTORY
PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY
Social Security or Death Certificate Number Date of Death County Code Year File Number
6\ 2or-1
Decedents Last Name Suffix First Name MI
ADDRESS OF DECEDENT STREEhh CI STATE: ZIP CODE
201yorK K� 2 1� 'lry Ml r,�i), A A f"707
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
NAME: 000 of Good
STREET ADDRESS 1' t � }I� I S ,TATE: ?IP C DFz
JULNAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING f�- f
a. NAME: RELATIONSHIP: n STR ET ADDRESS: CITY: STATE: ZIP CODE:
dew%SyAp'l
b. NAME: RELA`TI NSHIP:t c STREET ADDRESS. CITY: STATE: ZIP CODE:
eA
c. NAME: RELATIONSHIP: --�—
STREET ADDRESS: CITY: STATE: ZIP CODE:
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
NAME:r + aw f� h
STREF AMI SS^ [ ���(•✓� U�'t/� /� I CITY ( ttlrberL ST +'t— ZIi CQ t :
NA OF PERSON MAK I LAST E TRY r 1! DATE AN TIM OF ST ENTRY
17�nnaaa /d :o0AM
DATE OF CONTRACT TO RENT BOX • NUMBER OFO 1 TIT E UNDER WHICH eBOX ISAEQUESTED,
fra
NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX
a. NAME: b. NAME:
i NE �€cEASE.O. �o�e�a � Goe
STREET ADDRESS: STREET ADDRESS:
Sc P( tL. See dbe.re Vx t b.J
CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE:
NAME-AND TIT�Ee04MPLOYFATAKING THE INVENTOR r�n CIA
WAS A WILL IN THE BOX? ❑ YES [ NO If yes, a. Date of will::
b. Name and address of personal representative,if named in the will
NAME:
STREET ADDRESS: _ CITY: STATE: ZIP CODE:
\IRLlB� � �-c�t5
c. Name and address of attorney,if any C
NAME:
V
STREET ADDRESS: CITY: STATE: ZIP CODE:
48500041046 48500041046
I I .
REV-485 EX SAFE DEPOSIT BOX INVENTORY Page of
INSTRUCTIONS
(1) Cash:Report total only.
(2) Stocks:List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by
name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock.
(3) Obligations 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) All other contents.
(9) Return completed form to: DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT.280601
HARRISBURG,PA 17128-0601
ITEM ITEM DESCRIPTION
NO.
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I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
CORANDCOMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. S#K DEPOSIT BOX INVENTORY:
R AND COMPLETE
PRINT
01
GNATURE SIONATORE
i—I)A41a,
RINT NAM;EQ. PRINT NAME AND CHECK PROPRIATE BOX BELOW:
6vci�_
PRINT TITLE RI
CIEIK APPROPRIATE III:
Etorix) F�AdministratortDra, 61 M01WgCr (I/_/ 0 Estate Representative []Joint owner of safe deposit box
NOTE:Attach additional 81/2'x 111"sheet(s)if necessary or use duplicates of this page of form.
The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(i),to require disclosure of Social Security numbers in connection with administering state tax laws.The Department uses the
Social Security number to identify the decedent and personal representatives of the estate,The Commonwealth may also use the information in exchange of tax information agreements
with Federal and local taxing authorities.The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes.