Pennsylvania Request for Waiver or Notice of Transfer (For Stocks, Bonds, Securities or Security Accounts Held in Beneficiary Form (REV-516)

Request for Waiver or Notice of Transfer (For Stocks, Bonds, Securities or Security Accounts Held in Beneficiary Form (REV-516)
Notice of Transfer (For Stocks, Bonds, Securities or Security Accounts Held in Beneficiary Form) (REV-516)
5160019105
(EX) 05-19 (FI)

REV-516

OFFICIAL USE ONLY

Bureau of IndIvIdual Taxes
Po Box 280601
HarrIsBurg, Pa 17128-0601

SECTION I

File Number

NOTICE OF TRANSFER
(FOR STOCKS, BONDS, SECURITIES OR
SECURITY ACCOUNTS HELD IN
BENFICIARY FORM)

DECEDENT INFORMATION

START Decedent’s Last Name

Suffix

Decedent’s First Name

MI

➜

Date of Death (MMDDYYYY)

Social Security Number

County

Decedent’s Street Address

City

State

SECTION II

ZIP Code

CORPORATION, FINANCIAL INSTITUTION OR BROKER INFORMATION

Name of Corporation, Financial Institution, Broker or Similar Entity

Telephone Number

Firm’s Street Address

City

State

SECTION III

ZIP Code

ACCOUNT INFORMATION

Account Title

Account Number

Account Balance

Number of Beneficiaries

(Include accrued interest through date of death)

Account Type:
Capital Stock

SECTION IV

Registered Bond

Security Account

Other

RECIPIENT OF LETTER/PROOF OF NOTIFICATION
Suffix

Recipient’s Last Name

Recipient’s First Name

MI

Recipient’s Street Address

City

State

5160019105
Reset Entire Form

TOP OF PAGE

ZIP Code

5160019105

PAGE 1

NEXT PAGE

PRINT

5160019205

REV-516 (EX) MOD 05-19 (FI)

SECTION V

PREPARER INFORMATION

(Complete if Name and Address is different than Recipient information.)

Suffix

Preparer’s Last Name

Preparer’s First Name

MI

Preparer’s Street Address

City

State

Date (MMDDYYYY)

Preparer Signature

ZIP Code

Daytime Telephone Number

PLEASE SIGN AFTER PRINTING.

SECTION VI

BENEFICIARY INFORMATION

(List additional beneficiaries on Page 3.)

Suffix

Beneficiary’s Last Name

Relationship to Decedent

Beneficiary’s First Name

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

Suffix

Beneficiary’s Last Name

Relationship to Decedent

ZIP Code

Beneficiary’s First Name

MI

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

Suffix

Beneficiary’s Last Name

Relationship to Decedent

ZIP Code

Beneficiary’s First Name

MI

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

5160019205
Reset Entire Form

MI

PREVIOUS PAGE

ZIP Code

5160019205

PAGE 2

NEXT PAGE

PRINT

5160019305

REV-516 (EX) MOD 05-19 (FI)

SECTION VI cont.

BENEFICIARY INFORMATION

(Attach copies of page 3 to list additional beneficiaries.)

Suffix

Beneficiary’s Last Name

Relationship to Decedent

Beneficiary’s First Name

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

Suffix

Beneficiary’s Last Name

Relationship to Decedent

ZIP Code

Beneficiary’s First Name

MI

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

Suffix

Beneficiary’s Last Name

Relationship to Decedent

ZIP Code

Beneficiary’s First Name

MI

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

Suffix

Beneficiary’s Last Name

Relationship to Decedent

ZIP Code

Beneficiary’s First Name

MI

Beneficiary’s Social Security Number

Percent Taxable

Beneficiary’s Street Address

City

State

5160019305
Reset Entire Form

MI

PREVIOUS PAGE

ZIP Code

5160019305

PAGE 3

NEXT PAGE

PRINT

THIS PAGE DOES NOT PRINT

Pennsylvania Department of Revenue

Instructions for REV-516

notice of Transfer

rev-516 In (ex) 05-19

GENERAL INFORMATION

SECTION II

PURPOSE
Section 6411 of the Probate, Estates and Fiduciaries Code
(Title 20, Chapter 64, Pennsylvania Consolidated Statutes)
sets forth the requirement of reporting to the Department of
Revenue the transfer of securities.

Enter the information of the entity that maintains the
account.

WHO MUST FILE
Corporations, financial institutions, brokers, or similar
entities are required to report. The beneficiary, trustee or
representative of the estate may also notify the
department if all the necessary information is available
to them.
WHAT TO REPORT
Capital stock, registered bonds, a security or a security
account which are held as follows:

•

Held as sole owner by the decedent with a sole
beneficiary clause which controls distribution at the
death of the decedent.

•

Held as a sole owner by the decedent with a
primary and secondary (contingent) beneficiaries
clause which controls distribution at the death of
the decedent.

INSTRUCTIONS
If reporting more than one account, use a separate form for
reporting each account. If there is a main account made up
of sub-accounts, only report the main account number and
total value including the value of all sub-accounts. Assets
must be reported at their value as of the decedent’s date of
death, including any accrued interest not yet credited or
any dividend earned but not issued as of the date of death.
If available, include a copy of the valuation report.
Once a review of the form is complete, an acknowledgment
letter, confirming notification of the asset to the department,
will be issued to the person or entity reported in Section IV.
The letter may be used to demonstrate compliance of
section 6411. To ensure timely processing, each section of
this form must be completed as instructed below.

LINE INSTRUCTIONS
SECTION I
Enter the information for the decedent associated with the
asset being reported.

www.revenue.pa.gov

SECTION III
Enter the information for the asset being reported.
Account Title: Enter the name or title of the account.
Account Number: Enter the identifying number of
the account being reported.
Number of Beneficiaries: Enter the total number of
beneficiaries of the account being reported.
Account Balance: Enter the value of the account
including any accrued interest not yet credited or any
dividend earned but not issued as of the date of
death.
Account Type: Select the type of account that most
closely describes the account being reported. If
“Other” is used, enter the type of account in the space
provided.

SECTION IV
Enter the information for the person or entity who should
receive the acknowledgment letter that the asset has been
reported to the department.

SECTION V
Enter the name and address of the person preparing this
notice if the person is different from the person in Section
IV. The preparer must sign and date the form and provide
a daytime telephone number.

SECTION VI
Enter the information for each beneficiary of the account
being reported. If additional beneficiary space is needed,
use a separate sheet of Page 3 of this form.
Mail completed form to:
PENNSYLVANIA DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601

REV-516

1

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