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APPLICATION FOR CHARITABLE EXEMPTION
FROM PENNSYLVANIA TRANSFER INHERITANCE TAX
(Act of May 2B, 1956, P.L. 1757, and Act of June 15, 1961,
P.L. 373, as amended)
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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 #__~2~~.m'15
2. Date 01 Death ___ _FebrU"];L~,_1978__
17 c"4Y1~~ 3 /9, g
3. Date of Approval
7 (;8/.31
5. The Commonwealth's appraised value of the property for which an exemption is claimed is $ .L, r..7 or 1/9 of .residuE
(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 percentage amount above).
4. Name of Decedent Jr\'hn T C"Y'(:>Q!C!l A"Y'
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 Xl;
DEED 0;
TRUST INDENTURE 0;
SURVIVORSHIP 0;
OTHER 0;
(II ather, explain)
7. Correct Business Name and Address of Charitable Organization receiving property:
NAME
Mp.morial Lutheran Church of Shiooensburq, Pennsylvania
ADDRESS ~ornAr of Oranae and Penn Streets. Shippensbura. pennsylvania 17257
o See listing on reverse side for additional charitable organizations covered.
8. I certify that the information contained herein is, to the best of my knowledge and belief, true and correct.
The!~~t~;~.)~a:~. ': ~;ppAnFb"rg
Signature of Applicant BY: ~-{_/~P<- S
Addres s 01 Appl icant
1 west Kina street, Shippensburg, pennsylvania 17257
Official Title
Executor
Date
This form must be completed in triplicate and all three copies delivered ta 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 af Wills, deliver all three copies to the Director, Bureau of County Collections,
Penna. Department of Revenue, 26 S. 4th Street, Harrisburg, Pa.
Do not write below this line. For Official Use Only
APPROVED: Far the Secretary 01 Revenue REFERRED to Bureau Headquarters
Approved 0
For Secretary of Revenue
Denied* 0
{Signature of Register of Wil
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SItR OF WILLS
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")-]Cl ,-:3, ("1 '7 )/'
(Date 01 Approval)
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(Initials 01 Register 01 Wills)
(Authorized Signature)
(County)
(Title)
(Date 01 Relerral)
(Date 01 Action)
* See reverse side for reasons
MUST BE FILED IN TRIPLICATE
This section will be compl eted by Bureau Headquarters only when the application for exemption has been denied.
Date:
The application for exemption contained on the face of this form has been denied because
Note: Any party in interest, including the Commonwealth, aggrieved by this action may within sixty (60) days after
the date of this notice exercise their rights of Protest, Notice, or Appeal in accordance with the provisions of applicable
Pennsylvania Inheritance and Estate Tax Acts.