Rev-485 Ex - Safe Deposit Box Inventory Page 2
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2REV-485 EX (09-15)
Page
of
SAFE DEPOSIT BOX INVENTORY
INSTRUCTIONS
(1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by
name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock.
(3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership,
i.e., jointly held, payable on death, etc.
(4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and
branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible.
(8) All other contents.
(9) Return completed form to:
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
ITEM
ITEM DESCRIPTION
NO.
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS
PERSON RECEIVING COPY OF
CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SAFE DEPOSIT BOX INVENTORY:
SIGNATURE:
SIGNATURE:
PLEASE SIGN AFTER PRINTING THIS PAGE
PLEASE SIGN AFTER PRINTING THIS PAGE
PRINT NAME:
PRINT NAME AND CHECK APPROPRIATE BOX BELOW:
PRINT TITLE:
DATE:
CHECK APPROPRIATE BOX:
MM/DD/YYYY
Executor(trix)
Administrator(trix)
Estate Representative
Joint owner of safe deposit box
NOTE: Attach additional 8
1
/
” x 11” sheet(s) if necessary or use duplicates of this page of form.
2
The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department
uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information
agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth’s personnel from disclosing confidential tax information except for official purposes.
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