FILE IN DUPLICATE Will 20 No. Filed Adm. REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA COUNTY OF } } } ss. INVENTORY Personal Representative(s) of the Estate of Deceased, being duly sworn according to law, depose(s) and say(s) that the items appearing in the following inventory include all 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 value as of the date of the decedent’s death, and that decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verity that the statements made in this Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. } } } } } Attorney - (Name) (Sup. Ct. I.D. No.) (Address) DATE OF DEATH NOTE: LAST RESIDENCE DECEDENT’s SOCIAL SECURITY NUMBER The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative(s)include the value of each item, but such figures should not be extended into the total of the Inventory. (See Section 3301(b) or PEF Code of 1972) This form to be used only in estates of persons dying on or after February 23, 1956. APPENDIX A: Form 5 - Inventory © Philadelphia Bar Association and Wachovia Bank, National Association Blue Book