Pennsylvania Safe Deposit Box Inventory

Safe Deposit Box Inventory
Safe Deposit Box Inventory (REV-485)
4850019101
(EX) MOD 08-19

REV-485

BurEau Of InDIvIDual TaXEs
PO BOX 280601
HarrIsBurg, Pa 17128-0601

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SECTION I

SAFE DEPOSIT
BOX INVENTORY

DECEDENT INFORMATION

Decedent Last Name

Decedent First Name

Decedent Middle Name

County File Number

SECTION II

PLEASE USE ORIGINAL FORM ONLY

Date of Death MM/DD/YYYY

SSN (required)

REQUESTER INFORMATION

Name of Person Requesting the Opening of the Safe Deposit Box
Street Address
City
Signature

Title

State

ZIP Code

Date

MM/DD/YYYY

SIGN AFTER PRINTING
Name of Person(s) Present at the Box Opening

Relationship (if any)

Street Address
City

State

ZIP Code

State

ZIP Code

Please attach additional sheets if more people are present.

SECTION III

FINANCIAL INSTITUTION INFORMATION

Name of Financial Institution
Street Address
City

Name of Person Making Last Entry

Date of Last Entry

Date of Contract to Rent BoxMM/DD/YYYY

Number of Box

Time of Last Entry HH:MM

Title Under Which Box is Requested

Name of Person(s) Having Access to Box
Street Address
City

State

ZIP Code

Please attach additional sheets if necessary.
Name of Individual Taking Inventory

Title

4850019101
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4850019101

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4850019201

rEv-485 (EX) MOD 08-19

SECTION IV

INVENTORY

Was a Will in the Box?

Yes

If Yes, Date of Will

No

MM/DD/YYYY

Name of Personal Representative (If Named in the Will)
Street Address
City

State

ZIP Code

State

ZIP Code

Name of Attorney (If Any)
Street Address
City

ITEM NO.

ITEM DESCRIPTION

Please attach additional sheets if necessary.

SECTION V

CERTIFICATION

I certify under penalty of perjury that the above record is correct and complete to the best of my knowledge and belief.
Name

Signature

Title
SIGN AFTER PRINTING

Telephone Number

Email Address

Date

4850019201
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MM/DD/YYYY

4850019201

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Pennsylvania Department of Revenue

Instructions for REV-485

safe Deposit Box Inventory

rEv-485 In (EX) MOD 08-19

GENERAL INFORMATION
The Department is authorized by law, 42 U.S.C. §405
(c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The
Department uses the Social Security number to identify
the decedent and personal representatives of the estate.
The Commonwealth may also use the information in
exchange of tax information agreements with Federal and
local taxing authorities. The state law prohibits the
Commonwealth’s personnel from disclosing confidential
tax information except for official purposes.

LINE INSTRUCTIONS
SECTION I
DECEDENT INFORMATION
Enter information for the decedent, and the county file
number.

SECTION II
REQUESTER INFORMATION
Enter the name and address of the person requesting the
opening of the safe deposit box. The requester must then
sign and date.

SECTION IV
INVENTORY
Indicate if a will is in the box. If so enter the date.
Enter the name of the personal representative (if named in
the will) along with address.
Enter the name of attorney present (if any) along with
address.
List the items with description, and attach additional sheets
if necessary. Be sure to include:
• Cash: Report total only.
• Stocks: List in detail every common or preferred
certificate, warrant or other rights found in box.
Stocks are to be designated by name of company,
certificate number, date of certificate, name in which
stock is registered, and number of shares and class
of stock.
• Obligations of U.S. Government: Number of items,
date of issue, face value, names in which registered
and type of ownership, i.e., jointly held, payable on
death, etc.
• Bonds: Designate by name, amount, serial number,
or other designation. (Bearer Bonds)

The name and address of any present parties must be listed
along with relationship (if any) to the decedent. Please attach
additional sheets if needed.

• Bank and Savings and Loan Passbooks: State
name of depositor, number of book, last date
appearing in book, name of bank and branch, and
balance.

SECTION III

• Jewelry, Coins, Stamps, Manuscripts, etc: List and
describe as fully as possible.

FINANCIAL INSTITUTION INFORMATION
Enter the name and address of the financial institution where
the safe deposit box is located.

• Deeds, Mortgages, Current Insurance Policies or
other evidences of indebtedness: List and
describe as fully as possible.

Also list the name of person making last entry along with the
date and time. Include the date of contract, number of box
and title under which box is requested.

• All other contents.

Enter the name of person(s) having access to box along with
their address.
NOTE: Attach additional 81/2” x 11” sheet(s) if
necessary.

Return completed form to:
PA DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601

Enter the name and title of the individual taking the inventory.

www.revenue.pa.gov

REV-485

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