HomeMy WebLinkAbout12-04-14 SAFE DEPOSIT BOX
COIAIVOM%kiEALTH OF PENNSYLVANIA p P
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DEPARTMENT OF REVENUE IN ENTOR
INHERITANCE TA),DIVISION
DEPT.280601
HARRISBURG,PA 17128-0601 Please PrInt or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
G COUNTY CODE I FILE NUMBER
C>?/ /y- /D
DECEDENT'S NAME(LAST,FIRS MIDDLE) DATE OF�DEATH
may/ 2t l �D2 L�GT �2cP cJ
ADDRESS OF DEC EN_T (STREET) (CITY) (STATE) (ZIP CODE)
/ tet.n/ ,� . � •e �
NAME AND ADDRESS OF PERSON REQ STING THE OPENING OF THE SAFE DEPOSIT BOX
(NAME)
(STREETAMEN �/�) / (CITY) (STATE) (ZIP CODE)
NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,O PERSON(S)PRESENT AT THE BOX OPENING
a. (NAME;) (RELATIONSHIP)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
b. (NAME)
(RELATIONSHIP) �
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(STREET NAME (CITY) (STATE) (ZIP CODE)
C. (NAME) (R ATIONSHIP)
(STREET ME) (CITY) (STATE) (ZIP CODE)
/�Bu e
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE D SIT BOX IS LOCATED
(NAME)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
I NAME OF PERSON MAKING L T ENTRY,_, // DATE AND TIME LAST ENTRY
die
DATE OF CONTRACT TO kfNT BOX EM NUMBER OF BOX ED TITLE UNDER WHICH BOX IS REQUESTED
NANIE AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX
a. (NAME) b. (NAME)
(STREET ADDRE ) (STREET ADDRESS) O M
(CITY) (S E) (ZIP CODE) (CITY) �; F qW COZP
NAME AND TITLE OF EMPLOIEE TAKING THE INVENTORY CD
r-13 C3
O Of
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WAS A WILL IN THE BOX? ❑ YES VNO If yes, a. Date of will: F" in
b. Name and address of personal representative,if named in the willO") "�)
(NAME) CO
(STREET NAME) (CITY) (STATE) (ZIP CODE)
c. Name and address of attorney,if any
(NAME)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
1 7-0 ge
.............
I K 8:T FP\-U C-T-10 S
(1) Ca-sh: F,,epodLiLotal only.
(2) Stocks: List in detail every common or preferred certificate, vlarrant or other rights found in box. Stooks 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.
ITEM ITEM DESCRIPTION
NO.
47
3/
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECE&G COPY OF
CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPQ�$17, XINVENTORY: n
SIGNAT SI AT E
, -7 --/
T AM
PR14T NAME' SI
AME AND CHECK APPROPRIATE BOgLCW:
PRINT TITLE DA`FE CHECK APPROPRIATE BOX:
Z-Ex ..tor(trix) []Administrator(trix)
Estate Representative joint owner of safe deposit box
NOTE: Attach additional 81/2"x 11"sheet(s) if necessary or use duplicates of this page of form.