Form L-9 - Resident Decedents Only - New Jersey Department Of The Treasury (Page 2 of 2) in pdf

Form L-9 - Resident Decedents Only - New Jersey Department Of The Treasury Page 2

Beneficiaries

Interest of Beneficiary in the

State Full names of all who have an interest in the Estate

Relationship to the Decedent

Estate

(vested, contingent, operation of law, transfer, etc.)

Deponent further states the following schedule contains the names of all beneficiaries who predeceased the decedent.

Name

Date of Death

Domicile at Death

Did you remember to:

Fill in the decedent’s date of death and social security number.

Attach a copy of the decedent’s will, codicils, and/or trust agreements.

Attach a copy of letters testamentary or letters of administration.

Adequately describe the property listed: that is: street and number, lot and block number.

List the owner(s) of record on the title deed. (If multiple ownership state how property is held).

State the property’s full assessed, market, and equity values in the respective columns.

List all beneficiaries mentioned in the will, or heirs by intestacy, or joint owners on title deed.

Complete and Notarize

Name _________________________________________________ Phone (

) ___________________

Mailing Address

Street _________________________________________________________________________________

To Send

_________________________________________________________________________________

All Correspondence

City

___________________________________________ State __________ Zip ___________________

State of: ____________________________________________

County of: __________________________________________

That ____________________________________________________________________________ being duly sworn, has reviewed the

information contained in this form and declares to the best of his/her knowledge it is true, correct, and complete. Deponent authorizes the

party listed above to act as the estate's representative and to receive the waiver(s) requested herein.

Subscribed and sworn before me

this _____________ day of _______________________, 20______

Affidavit of:

Executor

Administrator

Heir

___________________________________________________________

_____________________________________________

(Signature of Notary Public or Attesting Officer)

Signature of Deponent

Form L-9 - Resident Decedents Only - New Jersey Department Of The Treasury Page 2