Form L-9 Affidavit Requesting Real Property Tax Waiver(S) For A Resident Decedent Page 4

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Beneficiaries
Interest of Beneficiary in the estate
State full names of all who have an interest in the estate
Relationship to the Decedent
(percentage or specific)
(vested, contingent, operation of law, transfer, etc.)
Deponent (person making deposition) further states the following schedule contains the names of all beneficiaries who predeceased the
decedent.
Name
Date of Death
Domicile at Death
If this form is not fully and properly completed and/or it does not have the required attachments, it will be returned. Did you
remember to:
o
Attach all required documents.
o
Fill in the decedent’s date of death and Social Security number.
o
Fully describe the realty to include the owner of record and the street number, municipality, lot, block, county, and the assessed
and market values on the decedent's date of death.
o
List all beneficiaries who shared in the estate whether by will, intestacy, trust, operation of the law, transfer intended to take
effect in possession or enjoyment at or after death, or by transfer within three years of death. Indicate the relationship of each
beneficiary to the decedent and the beneficiaries’ interests in the estate.
Complete and Notarize
Mailing Address
Name _________________________________________________ Phone (
) ___________________
To Send
Street _________________________________________________________________________________
All Correspondence
City
___________________________________________ State __________ Zip ___________________
State of: ____________________________________________
County of: __________________________________________
That ____________________________________________________________________________ being duly sworn, has reviewed the
information contained in this form and declares to the best of his/her knowledge it is true, correct, and complete. Deponent authorizes the
party listed above to act as the estate's representative and to receive the waiver(s) requested herein.
Subscribed and sworn before me
Affidavit of: oExecutor
o Administrator
o Joint Tenant
this _________ day of _____________________, 20______
___________________________________________________________
_____________________________________________
(Signature of Notary Public or Attesting Officer)
Signature of Deponent
__________________________________________________________
Print Name
__________________________________________________________
Deponent’s SS number or FID number
__________________________________________________________
Address
4

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