Form O-71 - Transfer Inheritance And Estate Tax - State Of New Jersey Division Of Taxation
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2STATE OF NEW JERSEY
FORM O-71
DIVISION OF TAXATION
(Rev. 3-11)
TRANSFER INHERITANCE AND ESTATE TAX
PO BOX 249
TRENTON, NJ 08695-0249
TO THE DIRECTOR, DIVISION OF TAXATION:
Pursuant to N.J.A.C. 18:26-11.30 and 18:26-11.31, notice is hereby given of the following sum or sums paid or payable by the
undersigned organization as a result of the death of:
NAME OF DECEDENT
SOCIAL SECURITY NUMBER
DATE OF DEATH
RESIDENCE AT DEATH (STREET ADDRESS)
MUNICIPALITY
COUNTY
POLICY OR CONTRACT NUMBER
DATE OF ISSUE
OWNER OF POLICY
DATE OF ASSIGNMENT
(IF OWNER-
SHIP ACQUIRED FROM DECEDENT)
KIND AND DESCRIPTION OF POLICY OR CONTRACT (DO NOT ABBREVIATE OR USE SYMBOLS)
ENDOWMENT
ANNUITY
LIFE INSURANCE
OTHER
BENEFICIARIES
AMOUNT
RELATIONSHIP AND SOCIAL
ADDRESS
NAME
PAID/PAYABLE
SECURITY #(If Available)
Face Amount of Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________________________
Dividends (Accumulated, post-mortem, terminal, and premium refunds) . . . . . . . . . . . . . . . . . . . .$ ________________________________
Other Amounts Payable (not including interest for period after death) . . . . . . . . . . . . . . . . . . . . . .$ ________________________________
Loan(s) Against Policy (as of date of death) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________________________
Proceeds payable (as of date of death) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________________________
Provisions of Policy Relating to Deferred Payments or Installments: ________________________________________________________
______________________________________________________________________________________________________________
Installment Payment: $_______________________ Per _____________________ Commuted Value $ ___________________________
Date of Birth (if available) of any Beneficiary Receiving Benefits For Life or a Term of Years: ____________________________________
Remarks :______________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
By signing this form the organization is declaring that each beneficiary listed on the form has or will be advised that information regarding
death claim payments is being supplied to the state pursuant to requirements of the New Jersey Division of Taxation and that it is the
position of the Division of Taxation that a beneficiary or beneficiaries may be personally liable for any and all inheritance and/or estate
taxes until paid in the absence of state or federal statutes to the contrary.
______________________________________________________
Name of Organization
Phone Number
______________________________________________________
Address
By: ___________________________________________________
Dated: __________________
______________________________________________________
Title
In every case where payment is made prior to this notice, state the date of payment under Remarks.
This form is used for decedents with a date of death after December 31, 2001
THIS FORM MAY BE REPRODUCED
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