REV-516 - Request for Waiver or Notice of Transfer
PERCENT TAXABLE
DECEDENT INFORMATION
REQUEST FOR WAIVER
OR
NOTICE OF TRANSFER
(FOR STOCKS, BONDS, SECURITIES OR
SECURITY ACCOUNTS HELD IN BENEFICIARY FORM)
BUREAU OF INDIVIDUAL TAXES
PO BOX 280601
HARRISBURG, PA 17128-0601
REV-516 EX + (08-13)
SIGNATURE OF PREPARER DAYTIME TELEPHONE NUMBER
Instructions for filing this notice are on the reverse side.
DECEDENT NAME: LAST FIRST MI
DECEDENT STREET ADDRESS CITY STATE ZIP COUNTY
DECEDENT SOCIAL SECURITY NUMBER DECEDENT DATE OF DEATH (MM-DD-YYYY)
ACCOUNT INFORMATION
TYPE OF ACCOUNT: CAPITAL STOCK REGISTERED BOND SECURITY ASSET SECURITY ACCOUNT OTHER
ACCOUNT TITLE
ACCOUNT WILL BE FILED ON REV-1500
BILL BENEFICIARIES SEPARATELY
ACCOUNT BALANCE (Include accrued interest through date of death)
IDENTIFYING NUMBER OF ASSET
BENEFICIARY INFORMATION
NAME:1. LAST FIRST MI
CITY STATE ZIP
RELATIONSHIP TO DECEDENT BENEFICIARY’S SOCIAL SECURITY NUMBER
STREET ADDRESS
CORPORATION, FINANCIAL INSTITUTION OR BROKER INFORMATION
NAME OF CORPORATION, FINANCIAL INSTITUTION, BROKER OR SIMILAR ENTITY TELEPHONE NUMBER
FIRM STREET ADDRESS CITY STATE ZIP
Official Use Only
TAX RATE
BENEFICIARY INFORMATION
NAME:2. LAST FIRST MI
CITY STATE ZIP
RELATIONSHIP TO DECEDENT BENEFICIARY’S SOCIAL SECURITY NUMBER
STREET ADDRESS
Official Use Only
TAX RATE
PERCENT TAXABLE
BENEFICIARY INFORMATION
NAME:3. LAST FIRST MI
CITY STATE ZIP
RELATIONSHIP TO DECEDENT
Please list additional beneficiaries on another sheet of paper, providing all required information.
BENEFICIARY’S SOCIAL SECURITY NUMBER
STREET ADDRESS
Official Use Only
TAX RATE
PERCENT TAXABLE
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