Form Et 13 - Application For Consent To Transfer The Proceeds Of Insurance Contracts, Employer Death Benefits And Retirement Plans For Resident And Nonresident Decedents Page 2

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ET 13
Rev. 4/12
Page 2
Part III – Benefi ts Payable by an Insurance Company (to be completed by insurer)
1. A consent is not necessary for straight life insurance payable to a named benefi ciary other than the estate.
2. Please complete Part V – listing all benefi ciaries’ information
3. A separate application consent form is not required for each benefi ciary. Please complete only one consent applica-
tion form for each policy or contract.
Name of insured
Owner of policy or contract
Name and address of insurance company
Type of policy or contract
Number of policy or contract
Value at date of death
If annuity, yearly payment
Part IV – Employment-Related Benefi ts (to be completed by employer)
1. A separate application consent form is not required for each benefi ciary. Please complete only one consent applica-
tion form for each death benefi t.
2. Please complete Part V – listing all benefi ciaries’ information
This form is not for IRAs and Keogh plans
Name and address of employer
held in a banking institution.
Use estate tax forms 12 and 14.
Date of death value $
Check one:
IRA
Keogh
Other
Lump sum $
Annually $
Monthly $
Other
Part V – Benefi ciary Information
Please complete the benefi ciary information as it applies to Part III and Part IV above.
Benefi ciary’s Name
Address
Relationship to Decedent
1.
2.
3.
4.
5.
6.

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