Report Of Death Form
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1TENNESSEE DEPARTMENT OF REVENUE
REPORT OF DEATH
TO: Inheritance Tax Unit
Director of Audit Division
Andrew Jackson State Office Building
Nashville, TN 37242
In accordance with Section 67-8-424, Tennessee Code Annotated, the following report of payment or approval of death claim
is made:
1. Name of Insured
Date of Death
2. Residence of Insured
County
3. Name and address of Beneficiary
4. Relation of Beneficiary to Insured
Date of Policy
5. Policy Number
6. Amount of Policy
Indebtedness Against Policy
7. Amount Actually Paid
Date of Payment
8. Manner of Payment
9. Remarks
10. Name of Insurance Company
11. Address of Insurance Company
RV-F1404001 (Rev. 9-03)
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