Form Ht-209 - Employe Death Benefit Report
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WISCONSIN DEPARTMENT OF REVENUE
Employe Death Benefit Report
Post Office Box 8904
Madison, Wisconsin 53708-8904
For deaths after 12-31-91
Telephone (608) 266-2772
1. Name of payor reporting
2. Name of plan
3. Name of deceased employe or former employe
4. Date of death
5. Address of decedent
6. Type of payment reported
Pension
Death benefit
Other (explain below)
Profit sharing
Wage Continuation
Annuity
Bonus
Deferred compensation
7. Amount of payment if paid in one sum
Date of payment
8. If payment will be made by installments, state number and amount of installments, age of beneficiary, mortality table and rate of
interest used in determining the value of the installments as of date of death.
Indicate value as of date of death
9. Names and addresses of beneficiaries
Relationship to decedent
Share of benefits payable
QUALIFIED
10. THE BENEFITS REPORTED ABOVE ARE PAYABLE UNDER A FEDERALLY
PLAN
NON-QUALIFIED
11. If the decedent contributed to the plan or toward the benefits reported on this form, please provide the following:
contributions by decedent $ ________________ contributions by employer to decedent's account $ _________________
CERTIFICATION
As representative of the payor named above, I certify that the information contained in this report is correct to the best of my knowledge
and belief.
Signature
Title
Date
IRA or HR 10 Plan
— This form does not have to be completed to report payments from an IRA or HR 10 Plan.
Section 72.34, Wisconsin Statutes provides that every person liable for paying benefits to the estate or a beneficiary of a deceased
employe or former employe in the form of an annuity, bonus, pension or other benefit under a retirement, deferred compensation or
profit-sharing plan taxable under this chapter, directly or through a trust or fund created by the employer for such purpose, shall give
notice of such obligation to the department within 30 days following the date of payment, or the date of the initial payment if more than
one payment is forthcoming, to the estate or any beneficiary of such employe or former employe.
HT-209 (R. 10-93)
Wisconsin Department of Revenue
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