Form 60-028 Estate Tax Joint Account Report Form 2004 printable pdf download

Iowa Department of Revenue

Iowa Inheritance/Estate Tax

Joint Account Report Form

Date ________________ , _______

Complete all applicable lines on this form.

To be completed and mailed by banks, credit unions, savings and loan associations, or any other person or

institution to the Iowa Department of Revenue upon report of the death of the owner of a joint account, as required

by section 450.97 of the Code of Iowa.

(1) Name of Reported Decedent __________________________________________________________________

(Use decedent’s first name, last name, and middle initial)

(2) Address of Reported Decedent ________________________________________________________________

_____________________________________________ , County _____________________________________

(3) Reported Date of Death ______________________________________________________________________

(4)

ACCOUNT NUMBERS

Name and Address of

Savings

Checking

Certificate of

Value

Surviving Owners

Relationship

Account

Deposit

Date of Death

________________________________________________________________________________________

(5) Name and Social Security Number of person(s) to which income is paid as reported on form 1099.

NAME

SOCIAL SECURITY NUMBER

________________________________________________________________________________________

(6) Date Released ____________________ , ________

(7) To whom released __________________________________________________________________________

Address ___________________________________________________________________________________

Phone Number ____________________________

(8) Name of institution reporting _______________________________________ City _____________________

(9) Name and title of institution representative making this report from its account record _________________

__________________________________________________________________________________________

Mail reports to:

EXAMINATION SECTION

Iowa Department of Revenue

PO Box 10456

Des Moines IA 50306-0456

60-028 (8/6/04)

Form 60-028 Estate Tax Joint Account Report Form 2004