Form Rev-1549 Ex (07-10) - Notice Of Decedent Account Status Page 4
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41549010401
REV-1549 WS
Decedent’s Social Security Number
Decedent’s Name:
D
LIST ALL JOINT SURVIVOR/BENEFICIARY INFORMATION BELOW
OFFICIAL USE ONLY
7.
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
8.
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
9.
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
Side 4
1549010401
1549010401
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Parent category: Financial