Form Et 13 - Application For Consent To Transfer The Proceeds Of Insurance Contracts, Employer Death Benefi Ts And Retirement Plans For Resident And Nonresident Decedents (Ohio Revised Code 5731.39)

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ET 13
Rev. 4/12
Estate Tax Unit
1-(800) 977-7711
Reset Form
tax.ohio.gov
Application for Consent to Transfer the Proceeds of Insurance Contracts,
Employer Death Benefi ts and Retirement Plans for Resident and
Nonresident Decedents (Ohio Revised Code 5731.39)
For dates of death July 1, 1983 – Dec. 31, 2012
Part I – Identifi cation
Name of decedent
Date of death
Decedent’s Social Security number
Decedent’s address at time of death (number and street, city, state and ZIP code)
County of residence
Case number
The gross value of all property held in the decedent’s name
Is the decedent’s estate in the process of administration?
alone or owned jointly by decedent at death or transferred
Yes
No
by the decedent prior to death; including, but not limited to:
real estate; cash; automobiles; household goods; insurance
Name and address of estate representative:
payable to an estate, pension plans and annuities payable
after death including IRA and Keogh plans (check accord-
ing to date of death):
Date of death (DOD) Jan. 1, 2002 – Dec. 31, 2012
More than $338,333
Under $338,333
DOD on or after Jan. 1, 2001 thru Dec. 31, 2001
More than $200,000
Under $200,000
Name and address of attorney representing estate:
DOD on or after June 30, 1983 thru Dec. 31, 2000
More than $25,000
Under $25,000
Note: If the gross estate is less than $338,333, $200,000
or $25,000 on the applicable date of death, no estate tax
return is required to be fi led.
I hereby certify that all statements made are correct to the best of my knowledge and belief. (Please provide name,
address and telephone number of person fi ling this application.)
Date submitted
Signature and title of applicant
(executor, administrator, survivor or attorney for same – circle one)
Applicant’s name
Address
City, state, ZIP code
Telephone number
Part II – To Be Completed By Agent of the Tax Commissioner (County Auditor) in the County
of the Decedent’s Residence
The application for consent to transfer is:
Approved
Not approved
Tax commissioner agent
By
Date

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