Pennsylvania Entry Into Safe Deposit Box To Remove A Will Or Cemetery Deed
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1REV-487 EX+ (10-11)
START
Date of Entry
ENTRY INTO SAFE
Month
Day
Year
DEPOSIT BOX
TO REMOVE A WILL OR
BUREAU OF INDIVIDUAL TAXES
Example 08/15/2004
CEMETERY DEED
PO BOX 280601
Please Print or Type
HARRISBURG, PA 17128-0601
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS.
1
2
3
DECEDENT’S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER (Required)
DATE OF DEATH
Example 08/15/2004
4
ADDRESS OF DECEDENT
Street Address
City
State
ZIP Code
5
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
Name
Street Address
City
State
ZIP Code
6
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
Name of Financial Institution
Street Address
City
State
ZIP Code
7
8
SAFE DEPOSIT BOX NUMBER
TITLE OR NAME(S) UNDER WHICH BOX IS REGISTERED
9
YES
NO
If yes
Date of will:
WAS THERE A WILL IN THE BOX?
Month
Day
Year
Example 08/15/2004
YES - An inventory will be completed at a later date in compliance with
NO
ARE THERE OTHER ITEMS IN THE BOX?
Sec. 2193 of the Inheritance and Estate Tax Act, 72 P.S. §9193
Name and address of personal representative(s), if named in the will:
Name
Street Address
City
State
ZIP Code
Name
Street Address
City
State
ZIP Code
Name and address of attorney, if any:
Name
Street Address
City
State
ZIP Code
Name
Street Address
City
State
ZIP Code
I certify under penalty of perjury to the best of my knowledge and belief that the above record is correct, complete and that
only a will and/or cemetery deed has been removed from the box at this time.
Signature
Date
Example 08/15/2004
PLEASE SIGN AFTER PRINTING.
Print Name
Title
The department is authorized under federal law, 42 U.S.C. § 405 (c), to use the decedent’s Social Security number in administering state tax laws.
The department uses Social Security numbers to establish a decedent’s identity and ensure proper credit for tax payments.
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