Page 1 of 2 Allegheny County, Pennsylvania Department of Court Records Wills/Orphans’ Court Division INVENTORY (form no:) Estate of ___________________________________________ No.________________________________ Also known as _____________________________________ Date of Death_________________________ ____________________________________, Deceased Social Security No. ________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair values as of the date of the Decedent’s death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative Name of Attorney: _______________________________________________ _______________________________________________ I.D No.: _______________________________________________ _______________________________________________ Address: _______________________________________________ _______________________________________________ _______________________________________________ Telephone: _______________________________________________ Description Value Total (Attach Additional Sheets if necessary) NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the inventory. [INVENTORY] American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 Inventory Continued Description Value Total NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the inventory. [INVENTORY] American LegalNet, Inc. www.FormsWorkflow.com