REV-1549 EX (07-10) (I)
1549010101
Commonwealth of Pennsylvania
Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
NOTICE OF DECEDENT
Harrisburg, PA 17128-0601
ACCOUNT STATUS
Phone: 717-787-8327
A
DECEDENT INFORMATION: Enter data as it will appear on all documents submitted to the Department.
MM/DD/YYYY
Social Security Number
Date of Death
County Code County
START
First Name
Last Name
Suffix
MI
Address
City or Post Office
State
ZIP Code
Zip Code + 4
B
B
ENTER FINANCIAL INSTITUTION INFORMATION
Fill in oval if name or address change.
Name of Financial Institution
Address
Financial Institution Bank ID Number
City or Post Office
State
ZIP Code
Zip Code + 4
C
ACCOUNT INFORMATION - PLEASE ATTACH COPY OF SIGNATURE CARD IF AVAILABLE
Fill in oval to indicate type of account
Joint Savings
Joint Checking
“In Trust For”
Joint Time Certificate
Account Number
Original Date Account was Established with Joint Survivor/Beneficiary
MM/DD/YYYY
Account Balance (Include interest to date of death)
$
s
s
PLEASE FILL IN OVAL IF ACCOUNT WAS ESTABLISHED BY A TRANSFER OF FUNDS FROM ANOTHER ACCOUNT THAT WAS
REGISTERED IN THE NAMES OF THE SAME JOINT OWNERS AND ENTER THE DATE ORIGINALLY ESTABLISHED.
Rollover Account - Date Originally Established
MM/DD/YYYY
Account Title as Appears on Signature Card or Certificate of Deposit
INDICATE ALL JOINT OWNERS/BENEFICIARIES ON REVERSE SIDE, AND WORKSHEET, IF APPLICABLE.
OFFICIAL USE ONLY
TRANSACTION COUNT
PLEASE USE ORIGINAL FORM ONLY
Side 1
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