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HomeMy WebLinkAbout09-12-78 RCC-42 (4-77) COMMONWEALTH Of PENNSYLVANIA OEPARTMENT OF REVENUE BANK NO. 15'J-:m-) D'Tfl.'~'f!18 NOTICE OF DECEDENT ACCOUNT STATUS RETURN COMPLETED FORMS TO LOCAL COUNTY INHERITANCE TAX OFFICE NAME SURVIVING DEPOSITOR (Beneficiary) INFORMATION REl.ATIONSHIP TO DECEDENT. ADDRESS BANKIINSTITUTlON ADDRESS ':!'he 1"1%'81. ? ."k '. ~rvCt. Co. ).1ain '~lr.\.tlt. ~~t,~. M!ll)hsrt1.0Ilbll7.'R,"~ 1.7oc;,; STA.TUS OF ACCOUNT NO: (JOINT, TRUST. OR INVESTMENT ~', I' SOCIAl. SECURITY NUMBER(S) NAMES ON ACCOUNT , ':'.:rri.at.. ~',. :}lii'J"'j.'... DECEDENT INFORMA I N DATE OF DEATH NAME ?/1'Jtr8 <: AODR J13 "1. ~~H~" rot.. CITY COU t'}.TY , ,~.'r"hR,. ZIP CODE l7t1~~ "'8ehnn1eBbu1"I BAl.ANCE OF ACCOUNT AT DOD INTEREST ACCRUED AND COl.l.ECTIBl.E AT 000 ToTAl. $ $ $ IlIC/./HI BANK AUTHORIZATION I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A CORRECT REPRESENTATION OF INFORMATION IN OUR FIl.ES IN ACCORD WITH SEe N 7 PIe. E TAX ACT OF 1961. $' '- "- .'<IIDnpIAIPU! IU.p....p .'11 '<q PJ.q sluno"V (E OO.~ '.pun .'UDIDq D ql!'" sluno"D IUlor' Il .sluno"D "II'" pUD puoqsnH (l :uo pa"!RbeJ S! J,loda.l ON .(P"ppD S!SD~dW3) ...(0(1;$) OJDlloP p"'punq a"'ql pe"'x" IOU saop qloap 10 "WII "ql "'0 Hsodap 8lfoJ uaq'" ."U"O:):)D If:)"S OJ plD a.. U! PEU!" &.. aq IIDlfs UO!lD;)!j!.JOu ON ....UOO:):)D 8'f1 0'" SJo^!A.lns .10 "OA!AJ"! GifIo fO ssa..ppo PUD .WOU 8'1'" PUD UO'.Jn.r.'.f.SU! ID!:)UDUfj 8'11 1f"'!M Ifloap fO aJDp elf'" 10 J,sodap UO.lO P....S&AU! lunOWD aq... '.uaWU8AU! .10 Hsodap ...sn..... .10 JUJoI elf'" JO UOHoa..:) 8'1'" fO GlOp ~Ut... 'uos.lad paSD8::tap 8lf1- JO awou alf'" 6u!^!6 jO&.I8'1'" anueA.H 10 lueWl'Ddea "ql "JlloU ~ 'IID"p "'1110 "6p"I"'ou~ '8.JfD sAop (ol) u.... ulql!M. uO!lnH.Jsu! IOPUOU!j 81.f1o fO ~np 81f'" eq 110'15 oJ! 'alp "olfs ,JuawIS8AU! .10 Hsodap alfl 0", S8'....Dd 8'11 fO auo PUD snufl'O ..0 18"11000 .I0J .Jsn,q V! Suos.led 10 UOIUtel D fO aWDU 8'11 VJ .10 8J!^' PUD puoqsn'i Uoap "8'1"'0 SUOS" alOw .10 0114 JO leWDU 8"'" Uf D!UDAI,(SUU8d u! pa,Jo;)01 UO!JnHUU! ID!:)UDUIJ D U! paISGAU!.I0 p8,J!sodap Sf .(auow U8'iA\... .S8!I.lDd P.l!1fI PUD "ll'" pUD pUDqsnq .<q Pl"q sluno..V IS .qlJOl DS pUD 'Sluno:):)o e.lo"s 'I!sodep 10 S.IO:J!f!......" so .,:Jns 'sluno:):Jo JU.WJS.AU! luror (t- sluno..V Isn,.1 (E sluno..V 6UI~'.q:> IUlor (Z sJuno:):)y S6U,ADS IUfOr ([ .1961 :10 .1:>V XV.13.1V.1S3 aNY 3:>NV.1IH3HNI 3H.1 :10 ?;lrl NOI.1:>3S :uo p..I!nb..1 S! l.Iod..1 y