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Form Et 6.01 - Appraisement Of The Estate For Decedents Dying On Or After July 13, 2001 Page 4

pArt 5: beneficiAries. List the names and relationships of all beneficiaries or heirs of the estate. Show the age of any life tenant

after their name. See page 3 of the instructions.

beneficiAry or heir

relAtionship

beneficiAry or heir

relAtionship

pArt 6: oAth of fiDuciAry

State of _______________________________________ County of ______________________________________, To-wit:

I, __________________________________, fiduciary for the estate of __________________________________________

after diligent effort to ascertain the taxable property of this estate, have made answers to each of the questions and have

completed, in detail, the schedules for each category of property and believe each item thereof to be correct. I thereby

believe the foregoing to be the true and lawful appraisement of ALL real estate and probate property of the estate of the

above named decedent.

___________________________________________________________

Fiduciary

Subscribed and sworn to before me this ____________ day of _______________________, 20________

___________________________________________________________

Notary Public

My Commission expires _________________, 20________

pArt 7: ApproVAl of fiDuciAry commissioner/fiDuciAry superVisor

I, ________________________, Fiduciary Commissioner/Fiduciary Supervisor of ___________________________ County,

West Virginia, to whom the estate of the above named decedent was referred, do hereby approve the foregoing appraisement

of such estate.

Given under my hand this ___________ day of _________________________, 20______________

________________________________________________

By ______________________________________________

Fiduciary Commissioner/Fiduciary Supervisor

Deputy

pArt 8: clerk of the county commission

STATE OF WEST VIRGINIA

COUNTY OF _________________________________, To-wit:

In the Clerk’s office of _____________________ County on the ________ day of ______________________, 20__________,

the forgoing appraisal of the above named decedent was presented and upon motion admitted to record.

Attest___________________________________________, Clerk

By____________________________________________, Deputy

Form ET 6.01

West Virginia State Tax Department

Page 4

Form Et 6.01 - Appraisement Of The Estate For Decedents Dying On Or After July 13, 2001 Page 4