HomeMy WebLinkAbout01-09-79
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLlCA TION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
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Rcc.n (9.68)
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made for coosent to the transfer of the following securities of a Pennsylvania
Corporotion or a National Banking Associalion locoted in Pennsylvanio:
(a) I-fo (1,,0 ) *" (b) RfliYIU) (c) (I 7lmrn6J-..-..
t~ (NOTE:. bin describ(inbg) sehcurities efnter in (a), ab Ole, either the number of shores of stock or the face omount of
registerea onds, in , t e name 0 the issuing company and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
::1u1'f 23, 196?'(z:9J
l' ISSUED ON ~ 1.1, /%J (7.<) ,and having a TOTAL MARKET V AilUE OF $ {,'( () (J. 0 ()
I ~<>tli'l 197[(20) ,II
">1' as of the date of death of the decedent, :kmec:; H /)iI2l"11o,rl?Dn1 ,If ,on ,.tun!" Iq 117'p
~ ~ (Neme of Decedent) (Date of death)
:~ who was late of 017 ?~ c:;7t'od 7<" })y f.:J1IJ/J /01 II IZI'/~I"/ IvvI /2
;....::::... (Street and Number) (~st Office) (County) (State)
1-<l The securities are registered as follows: ~m~ IlI&mS7l?o}<r1 -1. cJ.Ad ~ d/y?' f1 4-m:sW (J)u::;
j, (Name a, namesf.n which ce,Hficates a,e ,egiste,ed) j
''') ADMINISTRATOR) ST)I2671 .;J~oo Lo Cd II~_
:t EX ECLR=9R(>( ) /J Add,...)
NAME OF APPLICANT rc::, TII (Iff i Pi"
DATE
COUNTY FILE NUMBER .;t/- ')/r~ 3) e ADDRESS OF APPLICANT (?/~Cl 0 foe_eM
I
BUREAU FILE NUMBER SIGNATURE OF APPLlC" .
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS LICATION, I WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
COMMONWEALTH OF PENNSYL VANIA - DEPARTMENT OF REVENU E
CONSENT TO TRANSFER SECURITIES ~
DATE ""'. 9, 197
I hereby consent to the transfer of the above securities now registered in the name of th aforesaid r
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritonce tax to which
the property of said Decedent is made subject pursuant to the provisi~ns 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 Secretory of Revenue
~1A^1l, [' ~~lrM ~
R'mnR~!l..ft"f1m8lliJ '/
fitllh)ltlf"()~ WIUS
CUMBERlAND COUNll '
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(Title) (County)