REV-485 - Safe Deposit Box Inventory

ADDRESS OF DECEDENT STREET ADDRESS: CITY: STATE: ZIP CODE:

NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX

NAME:

STREET ADDRESS: CITY: STATE: ZIP CODE:

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:

NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY

DATE OF CONTRACT TO RENT BOX NUMBER OF BOX TITLE UNDER WHICH BOX IS REQUESTED

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:

NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY

WAS A WILL IN THE BOX? YES NO If yes, a. Date of will:

b. Name and address of personal representative, if named in the will

NAME:

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