Form Dr-301 - Preliminary Notice And Report
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1DR-301
Preliminary Notice and Report
R. 09/01
Mail To:
Florida Department of Revenue
Chapter 198, Florida Statutes, Notice of Death
5050 W Tennessee Street
Tallahassee FL 32399-0155
Include $5.00 fee.
Important Notice: Five dollar ($5.00) fee required for issuance of a nontaxable certificate. Failure to complete all blank spaces will result in delaying
the issuance of the proper certificate. If none, show “none.”
Decedent’s First Name and Middle Initial
Decedent’s Last Name
Decedent’s Social Security Number
Residence (Domicile) at Time of Death (County, State)
Date of Domicile
Florida Counties in Which Decedent Owned Real Estate:
Date of Death *
Name, Title, and Address of Personal Representative, or Person in Possession of Decedent’s Property
Name, Address, and Telephone Number of Attorney for Estate
If Estate is Being Administered, Give Title and Location of Court and Date of Appointment as Representative:
Send the Nontaxable Certificate to the Following Address:
Spouse Name
Social Security Number
-
-
Federal Estate I.D. # (If acquired)
Will this estate be filing a Federal Estate Tax Return? ❐ Yes ❐ No
* To be used for decedents with dates of death prior to January 1, 2000.
The decedent left an estate which consisted of: (
) only Florida property; (
) property situated both within and outside the State of Florida. The US property is described below. Attach schedule if needed.
Real estate in Florida (attach legal description for each piece of real property in which decedent owned any interest):
$ ______________________________________
_____________________________________________________________________________________________
$ ______________________________________
Tangible personal property in Florida: ________________________________________________________________
All Other US Property Wherever Situated:
$ ______________________________________
Real estate not in Florida: _________________________________________________________________________
$ ______________________________________
Stocks: _______________________________________________________________________________________
$ ______________________________________
Bonds: ________________________________________________________________________________________
$ ______________________________________
Mortgages: ____________________________________________________________________________________
$ ______________________________________
Notes: ________________________________________________________________________________________
$ ______________________________________
Cash: _________________________________________________________________________________________
$ ______________________________________
Insurance on decedent’s life and annuities: ___________________________________________________________
All other property including, but not limited to, jointly owned property (other than real estate) and Powers
$ ______________________________________
of Appointment: _________________________________________________________________________________
$ ______________________________________
Transfers during decedent’s life: ____________________________________________________________________
TOTAL
$
FOR OFFICE USE ONLY
I, ____________________________________________________________________________ hereby acknowledge
(Print name of personal representative or person authorized under s. 198.01(2), F.S.)
under oath that I have read the foregoing report and that the statements therein contained are true and that the same
correctly disclose all of the assets of the decedent named therein wherever located to the best of my knowledge and belief.
________________________________________________________________________________________________
(Signature of personal representative or person authorized under s. 198.01(2), F.S.)
______________________________________________________________________
___________________
(Title)
(Date)
State of _____________________ County of _________________________
Sworn to and subscribed before me this _______ day of ____________ , ______ .
Day
Month
Year
_____________________________ or _____________________________
Signature of Circuit Judge
Print, Type or Stamp Name of Notary
Personally known _____________ or produced identification ____________ .
Type of identification produced _____________________________________ .
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