Form 5 - In The Matter Of The Estate Of A Deceased Person - Wyoming Department Of Revenue - Excise Tax Division

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*0-0-1101-099*
     *0‐0‐1101‐099*
Wyoming Department of Revenue
Excise Tax Division
122 W. 25th Street, Herschler Bldg.
 
Cheyenne, Wyoming 82002-0110
IN THE MATTER OF THE ESTATE OF ______________________
, deceased.
Social Security Number: ________________________________________________________
The Decedent died (intestate) (testate). ___________________________________________
Date of Death: _________________________
Domicile at date of death (County and State): ______________________________________
Personal Representative: _______________________________________________________
Address: _____________________________________________________________________
Valuation of property in Wyoming: ______________________________________________
Total valuation of estate wherever located: ________________________________________
Was a 706 filed:__________yes___________no
I,_______________________________ , (attorney)(personal representative) for the estate of
____________________________deceased, do hereby certify that the foregoing information
is true and correct to the best of my knowledge and belief.
________________________________________________
Attorney or Personal Representative
Dated this ________day of __________________, 20___.
State of _________________________________________
County of _______________________________________
Subscribed to and sworn before me this _____day of___________, 20___, by
________________________________________________
Notary Public
My Commission expires: __________________________
ETS Form 5 (Revised 4/25/11)

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