61 Pa. Code § 93.43
(e) The financial institution shall require a statement which conforms substantially to the following form:
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.