The undersigned does hereby certify under penalty of perjury that there was mailed to the Department of Revenue, Harrisburg, Pennsylvania, and to the local office of the Department of Revenue, by certified mail, by me (if by another, state the identity of that person and his address), as evidenced by the record of the mailing made by the Post Office Department and attached hereto, and make a part hereof, and that the undersigned also mailed or caused to be mailed by ____________ (Name and address of party mailing the copy) At the same time a similar notice to ___ (Name and address of financial institution) that such notice fixed the ___ day of ___ 19 ___ at ___ (a.m.) (p.m.) Eastern Daylight or Standard Time and ___ as the place for entering the safe deposit box of ___ (Name of decedent) late of ___ who died ____________, such box being numbered ___.
The right of entry to this box is to be gained by ______________________________________(Explain entry).
This statement is made by the undersigned under penalty of perjury as provided for by the Inheritance and Estate Tax Act of 1961.
______________________________________
(Signature of party making application)
______________________________________
(Print name)
______________________________________
(Address)
61 Pa. Code § 93.43
This section cited in 61 Pa. Code § 93.34 (relating to entry with Department representative).