HomeMy WebLinkAbout04-19-78
RCC.12....{40:77l.; ,
BANK NO.
COMMONWEALTH Of PENNSYLVANIA :'N ;-071.t.7
DEPARTMENT OF REVENUE
DATE F1r'-IP:. t'l
NOTICE OF DECEDENT ACCOUNT STATUS Yo 1)/'{)
Submi t in truplicote within TIrlfoys ofter knoWfedge of STATUS OF ACCOUNT NO: (JOINT, TRUST, OR INVESTMENT
the deoth. 't"c'in~
'CO"
"":l,~ :+ ,~. r~, 1.~,,{ 0
RETURN COMPL ETED NAMES ON ACCOUNT SO CI AL SECU RI TY NUMBER{S)
FORMS TO LOCAL COUNTY ~""'1 ~{+~ 1 ~ ,." 1".,1-..1-,/') j
INHERITANCE TAX OFFICE "! t\ ;~:-~ .,: a.:-,t ..,:,'\1
SURVIVING DEPOSITOR (Beneficiary) INFORMATION DECEDENT INFORMA1nON
NAME RELATIONSHIP NAME DATE OF DEATH
wl:ltor TO DECEDENT.
SUITer Hnehand "'"l"( "ref' , .'i"',r , ' "'17
ADDRESS ADDRESS
12) E. leUer t.
:' '~GL ~1~.iC5 ~ ,~,l'g. r 17(\$5 L. 1 , 11.'1' ..
.. ....' ~.
CITY COUNTY - .-...".,
.
}jlJ!'';'. ......(: '.. OS , ,~:g ZIP CODE " /"",,);,J
BANK/INSTITUTION ADDRESS BAL.ANCE OF ACCOUNT AT 000 $
Tn. First Blink INTEREST ACCRUED AND COL.L.ECTlBL.E AT 000 $
" :r"r'. ~n +,; Co~;.a"7 TOTAL. $
....:..~ .~ ; ",,,,,1' n,: t ~,tB . BANK AUTHORIZATION
1'>;- ::-;~.m~ico;;. ,,"....l.ci, .:.. /\ 1 7r)'~r; I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A
CORRECT REPRESENTATION OF INFORMATION IN OUR FILES IN ACCORD
WITH SECTION 742 P I 8< E TAX ACT OF 1961.
SIGNATURE OF FINANCIAL INVESTIGATOR DATE
.
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