Form Rev-1549 Ex (07-10) - Notice Of Decedent Account Status Page 2
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41549010201
REV-1549 EX
Decedent’s Social Security Number
Decedent’s Name:
D
OFFICIAL USE ONLY
1.
Survivor’s Social Security Number
Relationship to Decedent
Percent Taxable
Last Name
Suffix
First Name
MI
First Line of Address
Tax Rate
Second Line of Address
City or Post Office
State
ZIP Code
Zip Code + 4
OFFICIAL USE ONLY
2.
Survivor’s Social Security Number
Relationship to Decedent
Percent Taxable
Last Name
Suffix
First Name
MI
First Line of Address
Tax Rate
Second Line of Address
City or Post Office
State
ZIP Code
Zip Code + 4
OFFICIAL USE ONLY
3.
Survivor’s Social Security Number
Relationship to Decedent
Percent Taxable
Last Name
Suffix
First Name
MI
First Line of Address
Tax Rate
Second Line of Address
City or Post Office
State
ZIP Code
Zip Code + 4
I certify that the information set forth on this form and all attachments thereto is true, correct, and complete.
NAME OF PREPARER - PLEASE PRINT:
TELEPHONE NUMBER:
E-MAIL ADDRESS:
DATE:
MM/DD/YYYY
Side 2
1549010201
1549010201
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