HomeMy WebLinkAbout10-03-78
RCC-72 (9-68)
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APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
COMMON";EAL Th"OF PENNSYL VANIA I
DEPARTMENT OF REVENUE I
_BUREAU OF ~OUNT~_~~~_~ECT~~~:~
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made for consent to the tl'ansfer of the following securities of a Pennsylvania
Corporation or a National Banking Associalion located in Pennsylvania:
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(NOTE: In describing securities enter in (a), ab (Ne, 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.)
DATE
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(a)
ISSUED ON ~~_-L-+-II 7 7
(Dote)
Q S of the dote of death of the decedent,
, and having a TOTAL MARKET V A'LUE OF $
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(Name of Decedent)
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(Date of death)
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who was late of __:~5- El.-, ,
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(Post Office) (County)
(State)
(Street and Number)
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The securities ate registered as follows: ~~b tll,....), ( '( O'_f'/ ,<, tk CI(',f,' v '-"~ 'ji 1"':1
(Name or names in which certificates are registered)
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(Name) '_(', (Adjlress,) ! '
NAME OF APPLICANT t ,'- '-'/'--iT\. L l ':':+,
COUNTY FILE NUMBER;( I~? (f-- 55~1 ADDRESS OF APPLlCANT'i)'; -e,\ (~fJJ.""" he-., :c",N'? K
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BUREAU FILE NUMBER________SIGNATURE OF APPLICANT <{'l~,.".,--< _Jt,>'.~,'.c_"
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT WILL NOT sF!'
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION. I
ADMINISTRA TOR)
EXECUTOR )
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES A\ ~ '::;.
DATE~21!i2 Y
I hereby consent to the transfer of the above securities now registered in the name of the aforesaid
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritance tax to which
the property of sQia Decedent is made subject pursuent 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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