Form Rev-485 Ex - Safe Deposit Box Inventory
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248500041046
REV-485 EX (05-04)
SAFE DEPOSIT
BOX INVENTORY
PA Department of Revenue
PLEASE USE ORIGINAL FORM ONLY
MM/DD/YYYY
YY
Social Security or Death Certificate Number
Date of Death
County Code
Year
File Number
START
Decedent’s Last Name
Suffix
First Name
MI
2
ADDRESS OF DECEDENT
STREET:
CITY:
STATE:
ZIP CODE:
3
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
4
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING
a. NAME:
RELATIONSHIP:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
b. NAME:
RELATIONSHIP:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
c. NAME:
RELATIONSHIP:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
5
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
6
7
NAME OF PERSON MAKING LAST ENTRY
DATE AND TIME OF LAST ENTRY
8
9
10
DATE OF CONTRACT TO RENT BOX
NUMBER OF BOX
TITLE UNDER WHICH BOX IS REQUESTED
MM/DD/YYYY
11
NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX
a. NAME:
b. NAME:
STREET ADDRESS:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
CITY:
STATE:
ZIP CODE:
12
NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
13
WAS A WILL IN THE BOX?
YES
NO
If yes, a. Date of will:
MM/DD/YYYY
b. Name and address of personal representative, if named in the will
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
c. Name and address of attorney, if any
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
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48500041046
48500041046
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