Form 17-100 - Inheritance Tax Small Estate Return - Resident

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COMPTROLLER OF PUBLIC ACCOUNTS

17-100

(Rev.5-02/6)

STATE OF TEXAS

INHERITANCE TAX SMALL ESTATE RETURN - RESIDENT

NOTE: The following requirements must be met in order to use this return:

• Do not write in shaded areas.

• Date of death of decedent must be before September 1, 1981.

T Code

90100

Deposit Code

110

• Decedent was a resident of Texas at date of death.

Date received by Comptroller

Amount

• Total gross estate does not exceed $200,000.

• No Federal Estate Tax has been paid or is due on this estate.

Decedent’s name (First, middle, maiden, last)

Social Security Number

Date of birth

County of residence (domicile at death)

Probate case number

County of probate

Date of death

Disclosure of your social security number is required and authorized under law, for the purpose of tax administration and identification of any individual affected by applicable law.

42 U.S.C. sec. 405(c)(2)(C)(i); Tex. Gov't Code secs 403.011 and 403.078. Release of information on this form in response to a public information request will be governed by the

Public Information Act, Chapter 552, Government Code, and applicable federal law.

• Valuation date elected:

Value at date of death

Alternate value date

• Within 3 years immediately preceding death, did the decedent make

any transfer of property without an adequate and full consideration?

YES

• If “YES,” please explain (See instructions)

List below values of property owned by the decedent. Report community assets and debts at decedent’s one-half interest.

Give details on reverse side of this form or attach a complete inventory and appraisement.

ASSETS

DEDUCTIONS

1. Real estate located in Texas ............... $

11. Mortgages and liens ............................. $

2. Stocks and bonds ...............................

3. Mortgages, notes and cash .................

12. Other deductible debts .........................

4. Insurance subject to exemption

(In excess of $40,000) ........................

13. Deductible expenses ............................

5. Insurance not subject to exemption ....

14. Deduction for property

6. Annuities .............................................

previously taxed ...................................

7. All other assets ...................................

15. TOTAL DEDUCTIONS

(Total Items 11 - 14) ............................. $

8. TEXAS GROSS ESTATE

(Total of Items 1 - 7) ............................

16. TOTAL NET ESTATE

(Item 10 minus Item 15) ....................... $

9. Out of state real or tangible property ..

TOTAL NET ESTATE value is to be distributed in

10. TOTAL GROSS ESTATE

(Item 8 plus Item 9) ............................. $

Section VII on the reverse side of this form.

BASIC INHERITANCE TAX

(Total of Column 8, “Texas Inheritance Tax,” from the reverse side of this form.) ..................................................... $ _______________________

PLEASE NOTE: Forms will not be processed unless completely filled in. The return must be signed by the personal representative of the estate and

person preparing the return. Copy of decedent’s will, if probated, or Affidavit of Heirship must be attached.

I declare that this return and any accompanying statements are true, correct and complete to the best of my knowledge and belief. I understand that this return is subject to

the fraudulent report provisions of TEX. TAX GEN. ANN. art. 1.12(1969).

Name of preparer

Phone (Area code & no.)

Name of Executor, Administrator., Heir at Law

Phone (Area code & no.)

Address (Street & no., city, state, ZIP code)

➧

Preparer

Date

➧

Executor, Administrator, Heir at Law

Date