Form Ih-19 - Notice Of Intended Transfer Of Checking Account
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1Prescribed by the Indiana Department of Revenue
Form IH-19
State Form 48837
(R2 / 04-07)
NOTICE OF INTENDED TRANSFER OF CHECKING ACCOUNT
Name of Decedent
Social Security Number
Address
County of Residence
Date of Death (if known)
Under Code § 6-4.1-8-4.6, notice is hereby served that the checking account of the decedent qualifying under said statute, in
the possession or control of the undersigned, has been transferred to an individual other than the surviving spouse and the following
information is given concerning such property:
Description
Account
Form
Fair Market Value
of
Number
of
at
Property
Ownership
Date of Death
Name
Relationship
Phone Number
Address
of
to
of
of
Transferee(s)
Decedent
Transferee(s)
Transferee(s)
Date of Transfer
HOLDING INSTITUTION OR TRANSFER AGENT
NOTE: (If you will enclose a self-addressed,
Name
stamped envelope and two copies of
this Notice, one will be returned to
Address
you stamped with the date it is re-
ceived and the name of the offi ce
City
State
Zip Code
receiving it.)
Signature of Authorized Offi cial
(Phone)
This notice must be provided to the county assessor of the county in which the resident decedent was domiciled
at the time of death, or to the Indiana Department of Revenue.
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