Stocks/Bonds Inventory (REV-1381)

ReV-1381 eX (10-09)

PO BOX 280601 HARRISBURG PA 17128-0601

NUMBER SHARES/ DENOMINATION

CLASS/SERIES

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STOCKS/BONDS ? INvENTORY

To be used in conjuncTion wiTh ReV-485 esTaTe of file numbeR

social secuRiTy numbeR

COMPANY NAME

CERTIFICATE/BOND NUMBER

ISSUE DATE

MM/DD/YY

STOCKS/BONDS REGISTERED IN NAME(S) OF

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