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Form 12 - Application For Consent To Transfer Property Or Other Interest Of A Resident Decedent (5731.39 O.r.c.) Page 2

Estate Tax Form 12

Revised 12/00

a. Is the decedent’s estate in the process of administra-

d. The gross value of all property held in the decedent’s

tion?

name alone or owned jointly by decedent at death or

Yes c

No c

transferred by the decedent prior to death; including,

but not limited to: real estate; cash; automobiles;

b. Name and address of estate representative:

household goods; insurance payable to an estate,

pension plans and annuities payable after death

____________________________________________

including IRA and Keogh plans (check according to date

of death):

____________________________________________

D.O.D. on or after June 30, 1983 thru December 31, 2000

c Over $ 25,000

c Under $ 25,000

____________________________________________

D.O.D. on or after January 1, 2001 thru December 31, 2001

c. Name and address of attorney representing estate:

c Over $200,000

c Under $200,000

D.O.D. on or after January 1, 2002

____________________________________________

c Over $338,000

____________________________________________

If the gross taxable estate is less than $25,000, $200,000 or

$338,000 on the applicable date of death, no estate tax return

____________________________________________

is required to be filed.

I hereby certify that all statements made are correct to the best of my knowledge and belief

PRINT or TYPE name, address and telephone number

of person filing this application.

___________________________________________________

Signature and Title of Applicant

(Executor, Administrator, Survivor or Attorney for Same)

__________________________________________________________________________________________________

Address

City and State

Telephone No.

Date Filed ______________________

Instructions for Completing Form 12

Note:

A consent to transfer is not required for funds on deposit if the only beneficiary is the surviving spouse.

Effective January 1, 2001, pursuant to the Tax Commissioner’s authorization, a consent to transfer is not re-

quired for funds on deposit if the amount is $25,000 or less per account.

If a release is required, follow these instructions.

A. Bank accounts and funds on deposit, including IRA’s and Keogh Plans, in a savings and loan association

or other banking institution – Provide the Following:

1. Name of institution

2. Amount on deposit as per last entry prior to death and date of last entry

3. Type of account

4. Identifying number and the manner in which the fund is registered

Bank books and certificates of deposit must accompany this application.

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Form 12 - Application For Consent To Transfer Property Or Other Interest Of A Resident Decedent (5731.39 O.r.c.) Page 2

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