Form Rev-516 Ex - Request For Waiver Or Notice Of Transfer - Pennsylvania Departament Of Revenue

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REV-516 EX + (08-13)
REQUEST FOR WAIVER
OR
NOTICE OF TRANSFER
(FOR STOCKS, BONDS, SECURITIES OR
BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
SECURITY ACCOUNTS HELD IN BENEFICIARY FORM)
HARRISBURG, PA 17128-0601
DECEDENT INFORMATION
START
DECEDENT NAME:
LAST
FIRST
MI
DECEDENT SOCIAL SECURITY NUMBER
DECEDENT DATE OF DEATH (MM-DD-YYYY)
DECEDENT STREET ADDRESS
CITY
STATE
ZIP
COUNTY
CORPORATION, FINANCIAL INSTITUTION OR BROKER INFORMATION
NAME OF CORPORATION, FINANCIAL INSTITUTION, BROKER OR SIMILAR ENTITY
TELEPHONE NUMBER
FIRM STREET ADDRESS
CITY
STATE
ZIP
ACCOUNT INFORMATION
TYPE OF ACCOUNT:
CAPITAL STOCK
REGISTERED BOND
SECURITY ASSET
SECURITY ACCOUNT
OTHER
ACCOUNT BALANCE (Include accrued interest through date of death)
IDENTIFYING NUMBER OF ASSET
ACCOUNT TITLE
ACCOUNT WILL BE FILED ON REV-1500
BILL BENEFICIARIES SEPARATELY
BENEFICIARY INFORMATION
1.
NAME:
LAST
FIRST
MI
PERCENT TAXABLE
STREET ADDRESS
Official Use Only
CITY
STATE
ZIP
TAX RATE
RELATIONSHIP TO DECEDENT
BENEFICIARY’S SOCIAL SECURITY NUMBER
BENEFICIARY INFORMATION
2.
NAME:
LAST
FIRST
MI
PERCENT TAXABLE
STREET ADDRESS
Official Use Only
CITY
STATE
ZIP
TAX RATE
RELATIONSHIP TO DECEDENT
BENEFICIARY’S SOCIAL SECURITY NUMBER
BENEFICIARY INFORMATION
3.
NAME:
LAST
FIRST
MI
PERCENT TAXABLE
STREET ADDRESS
Official Use Only
CITY
STATE
ZIP
TAX RATE
RELATIONSHIP TO DECEDENT
BENEFICIARY’S SOCIAL SECURITY NUMBER
Please list additional beneficiaries on another sheet of paper, providing all required information.
PLEASE SIGN AFTER PRINTING.
SIGNATURE OF PREPARER
DAYTIME TELEPHONE NUMBER
Instructions for filing this notice are on the reverse side.
RETURN TO TOP OF PAGE
INSTRUCTION PAGE
Reset Entire Form
PRINT FORM

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