Schedule "E" Transfers Non-Resident Decedent Form - Department Of Treasury
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1SCHEDULE “E” TRANSFERS
NON-RESIDENT DECEDENT
_______________________________________________________
____________/____________/____________
Decedent’s Name
Decedent’s Social Security Number
(ALL QUESTIONS MUST BE ANSWERED)
1. Did decedent, within three years of death, transfer property, valued at $500.00 or more, without receiving
full financial consideration therefor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
2. Did decedent, at any time, transfer property, reserving (in whole or in part) the use, possession, income,
or enjoyment of such property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
3. Did decedent, at any time, transfer property on terms requiring payment of income to decedent from a
source other than such property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4. Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change
because of a reserved power to alter, amend, or revoke, or which could revert to decedent under terms
of transfer or by operation of law? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If answer to any of above questions is “yes”, set forth a description of property transferred, the fair
market value at date of death, dates of transfers, and to whom transferred. Submit copy of trust deed or,
agreement, if any. (If transfers are claimed to be untaxable, also submit detailed statement of facts on which
such claim is based, proof as to decedent’s physical condition and copy of death certificate.)
5. Was decedent a participant in any pension plan that provided for payment of an annuity or lump sum on
or after death to another? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
6. Did decedent purchase or in any manner participate in any contract or plan providing for payment of an
annuity or lump sum on or after death to another, except life insurance contracts payable to a designated
beneficiary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
(Matured endowment policies, claim settlement certificates, supplementary contracts, annuity contracts
and refunds thereunder and interest income certificates even though issued by an insurance company are
not considered life insurance contracts.)
7. Was a single premium life insurance policy issued on decedent’s life in conjunction with an annuity
contract? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If answer to questions 5, 6 or 7 is “Yes”, attach a copy of all such contracts, plans, and policies.
8. Were any accumulated dividends due on any contract of insurance? (If yes, list below) . . . . . . . . . . . . . . . . .
Yes
No
Date of Transfer; Description of Property, Both Real and Personal:
Actual Consideration if Any; Names and Relationship to
Market Value
This Column for
Decedent of Donees, Assignees, Transferees, etc.
at Date of Death
Division Use
Insert this total on page 1, line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(If additional space is required, attach riders of the same size)
IT-NR Page 12
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