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RCC-72 (9-68\
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLICATION 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 for consent to the transfer of the following securities of a Pennsylvania
Corporation or a National Banking Association located in Pennsylvania:
DA TE April 10, 1979
(a) 70 (b) PeIm Pacific Cbrp. (fomerly Perm ~te ~~ Corp.) Cama1
(NOTE: In describing securities enter in (a), ab Ole, either the number of shares of stock or the face amount of
registered bonds, in (b), the name of the issuing company and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
ISSUED ON 2/13/64; 4/28/65 , and having a TOTAL MARKET V AtUE OF $
(Date)
as of the date of death of the decedent, A. Raymmd Eppley
(Name of Decedent)
109.38
, on
Sept. 1, 1978
(Date of death)
who was late of
Plainfield, PeDsylvania
ClIdJerland OJunty
(Street and Number)
(Post Office)
(County)
(State)
The securities are registered as follows:
A. Raynxmd Eppley
(Name or names in which certificates are registered)
ADMINISTRATOR) Farmars Trust Co., 01e West High st., Carlisle, Pem1a. 17013
EXECUTOR) (Name) ~d~ ~"'''''Y
NAME OF APPLICANT ~
Carlisle, Pem1a. 17013
COUNTY FILE NUMBER 21 78 482 ADDRESS OF APPLICANT__
BUREAU FILE NUMBER SIGNATURE OF APPLICANT /1(J'IC'LJ.-/JH~j{! I \fp'i-r(\
NOTICE: IF YOU FAIL TO PROPERL.Y FILL IN ANY PORTION OF THIS APItrfICATlON, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES ~ 10. Jon
DATE ',. ~'11
I hereby consent to the transfer of the above securities now registered in the name of the af esaid
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.
Signed for the Secretary of Revenue
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