HomeMy WebLinkAbout06-22-78
RCC'72 (9.681
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLlCA TlON FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
'*,
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made far cansent to the transfer of the fallowing securities of a Pennsylvania
Corporation or a National Banking Assacialian located in Pennsylvania:
DA TE June 22, 1978
(a) 242 (b) Fortune National Corporation ____ (CL. COIII11on
(NOTE: In describing securities enter in (a), ab cye, either the number of shares of stack or the face amount of
registered bands, in (b), the name of the issuing company and in (c) the class of stack or the stated interest rate
and maturity date of registered bands.) 11126/76 - 11 shares; 11126/75 - 11 shares; 11129/74 _
10 shares; 11130/73 - 10 shares; and 5/15/72 - 200 shares
ISSUED ON ,and having a TOTAL MARKET VAtUE OF $ 1,028.50
(Date)
as of the date of death of the decedent, George M. Heckert, Jr.
(Name of Decedent)
on March 17, 1978
, .
(Date of death)
who was late of 5 Stone Spring Lane
Camp Hill
Cumberland
(Street and Number)
(Post Office)
(County)
Pennsylvania
(State)
The securities are registered as follows: George M. Heckert, Jr.
(Name or names in which certificates ore registered)
~ E. Robert Elicker, II, 1805 _C1a~n.don.Street,j::amp HillL Pennsylvania
EXECUTOR) (Name) (Add,ess)
NAME OF APPLICANT E. Robert Elicker, II 13,~~u ~
----nUS-Clarendon SFreet
COUNTY FILE NUMBER 21-78-151 ADDRESS OF APPLICANT _ Camp_Hill, I'A 17011
BUREAU FILE NUMBER SIGNATURE OF APPLICANT f IflttJ)c!~dR.A-.J ;:11
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES\..
..-.-- DATE~~-=?')
I hereby consent to the transfer of the above securities now registered in the name of thc.laforesaid .
(97f'
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritance tax to which
the property of said Decedent is made subject pursuant to the provisions of the Act of June 20, 1919, P.L. 521,
as amended and the Act of June 15, 1961, P.L. 373, as amended. This is also in accordance with the provisions
of the Act of April 9, 1929, P.L. 343.
This Consent to Transfer the herein described property operates only in reference to the estate of the
above-named Decedent.
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Signed for the Secretary of Revenue
6~~. C~A~I]Q~ ';) ~
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t::GISTER OFWUU.I
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