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Notice of Transfer (For Stocks, Bonds, Securities or ...

REV-516 Bureau of IndIvIdual Taxes Po Box 280601 HarrIsBurg, Pa 17128-0601 OFFICIAL USE ONLYNOTICE OF Transfer ( for stocks , BONDS, Securities OR SECURITY ACCOUNTS HELD IN BENFICIARY FORM)PAGE 1 File Number DECEDENT INFORMATIONSECTION I CORPORATION, FINANCIAL INSTITUTION OR BROKER INFORMATIONSECTION II ACCOUNT INFORMATIONSECTION III RECIPIENT OF LETTER/PROOF OF NOTIFICATIONSECTION IVCapital StockRegistered BondSecurity AccountOtherAccount Type:Recipient s Street AddressRecipient s Last NameSuffixRecipient s First NameMIAccount TitleAccount NumberNumber of BeneficiariesFirm s Street AddressName of Corporation, Financial Institution, Broker or Similar EntityTelephone NumberZIP CodeCityStateZIP CodeCityStateAccount Balance(Include accrued interest through date of death)Decedent s Street AddressDecedent s Last NameSuffixDecedent s First NameMIDate of Death (MMDDYYYY)Social Security NumberCountyZIP CodeCityState51600191055160019105(EX) 05-19 (FI)5160019105 PREPARER INFORMATION (Complete if Name and Address is different than Recipient information.)

Capital stock, registered bonds, a security or a security ... 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 …

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  Bond, Transfer, Securities, Valuation, Stocks, For stocks

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