Form R-3405 - Affidavit Of Small Succession 2002
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1R-3405 (4/02)
State of Louisiana
Form IETT-103
Department of Revenue
P. O. Box 201
Baton Rouge, LA 70821-0201
Affidavit of Small Succession
This is to be used only for estates that meet all the requirements in the declaration below.
Estate of
Marital status of decedent
( ) Married ( ) Single ( ) Widowed
Address of decedent at time of death (number and street, city, state, ZIP)
Date of death
Decedent’s Social Security Number
Designated parish of decedent
Declaration
Upon my/our oath, I/we solemnly swear that the information on this form and the following statements are true and correct:
1. The decedent died intestate (i.e., no will);
2. The value of the decedent’s succession does not exceed $50,000 (based on gross assets);
3. The decedent’s estate contains no immovable property (i.e., real estate); and,
4. The decedent’s sole heirs are his/her descendants, ascendants, brothers or sisters, or descendants thereof, or surviving spouse.
Under the penalties of perjury, I/we declare that this affidavit, including any accompanying schedules and statements, is to the best of my/our knowledge
and belief, a true, correct, and complete identification of the death circumstances and legal heirship of the named decedent.
Enter name and address of heir.
Enter name and address of heir.
Name ___________________________________________________
Name ___________________________________________________
Address __________________________________________________
Address __________________________________________________
City, State, ZIP ____________________________________________
City, State, ZIP ____________________________________________
SSN#
SSN#
Relation __________________________________________________
Relation __________________________________________________
Signature _________________________________________________
Signature _________________________________________________
Enter name and address of heir.
Enter name and address of heir.
Name ___________________________________________________
Name ___________________________________________________
Address __________________________________________________
Address __________________________________________________
City, State, ZIP ____________________________________________
City, State, ZIP ____________________________________________
SSN#
Relation __________________________________________________
SSN#
Relation __________________________________________________
Signature _________________________________________________
Signature _________________________________________________
(If more than four, please attach supplementary list.)
Enter name and address of surviving spouse.
Enter name and address of preparer.
Name
Name
Address
Address
City, State, ZIP
City, State, ZIP
Telephone (
)
Telephone (
)
Signature
Signature
A descriptive list (or inventory) and values of property owned by the decedent at date of death must accompany affidavit.
An inheritance tax return (Form IETT-100) must accompany this affidavit if the gross estate is $15,000 or more, or if any taxes are due.
This affidavit must be notarized before it is submitted to the Secretary of Revenue.
For office use only. Do not write in this block.
Sworn to and subscribed before me this
day of
,
.
year
Based upon the foregoing facts, inheritance tax in the
amount of $ ___________ is due and has been paid
to the State of Louisiana.
Notary Public
By _____________________________________
Louisiana Department of Revenue
For assistance with inheritance tax questions, call the Inheritance,
Telephone: (225) 219-0067
Gift, and Estate Transfer Taxes Section at (225) 219-0067, TDD
(225) 219-2114, or write to:
Date:
/
/
Louisiana Department of Revenue
Inheritance, Gift, and Estate Transfer Taxes Section
P. O. Box 201
Baton Rouge, LA 70821-0201
The Department of Revenue retains the right of review
under Article 2954 of the Code of Civil Procedure.
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