Form Rev-1549 Ex (07-10) - Notice Of Decedent Account Status Page 3
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4REV-1549 EX (07-10) (I)
1549010301
NOTICE OF
DECEDENT ACCOUNT
Decedent’s Social Security Number
STATUS WORKSHEET
Decedent’s Name:
D
OFFICIAL USE ONLY
4.
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
Zip Code + 4
City or Post Office
State
ZIP Code
OFFICIAL USE ONLY
5.
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
Zip Code + 4
City or Post Office
State
ZIP Code
OFFICIAL USE ONLY
6.
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
Zip Code + 4
City or Post Office
State
ZIP Code
PLEASE USE ORIGINAL FORM ONLY
Side 3
1549010301
1549010301
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Parent category: Financial