REV-487 - Entry into Safe Deposit Box to Remove a Will or Cemetery Deed
BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
HARRISBURG, PA 17128-0601
ENTRY INTO SAFE
DEPOSIT BOX
TO REMOVE A WILL OR
CEMETERY DEED
Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS.
DECEDENT’S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER (Required) DATE OF DEATH
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 AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
Name of Financial Institution
Street Address City State ZIP Code
SAFE DEPOSIT BOX NUMBER TITLE OR NAME(S) UNDER WHICH BOX IS REGISTERED
WAS THERE A WILL IN THE BOX?
YES NO If yes Date of will:
Month Day Year
ARE THERE OTHER ITEMS IN THE BOX? YES - An inventory will be completed at a later date in compliance with NO
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.
REV-487 EX+ (10-11)
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Date of Entry
Month Day Year
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.
Signature Date
Print Name Title
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