Form Au-101-C - Legacy, Succession And Estates Trust Report
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1
2FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
AU-101-C
LEGACY, SUCCESSION AND ESTATES
TRUST REPORT
DECEDENT'S LAST NAME
FIRST NAME
MIDDLE INITIAL
DECEDENT'S SSN
DATE OF DEATH
STEP 1
Please
Print or
DOMICILE AT DATE OF DEATH
STREET
CITY/TOWN
STATE
ZIP CODE
APPLICABLE NH COUNTY
NH PROBATE NUMBER
Type
TRUSTEE OR SUCCESSOR TRUSTEE NAME
STREET ADDRESS
CITY/TOWN
STATE
ZIP CODE
* All of the following information, including the fair market value, MUST be provided even if the legatees are non-taxable.
STEP 2
Type of
INITIAL
AMENDED
Filing
STEP 3
Fair market Value
Property
Of Property At
Relationship To
Property Description
Date of Death
Name Beneficiary
Decedent
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
9
$
10
$
11
$
12
$
13
$
14
$
STEP 4
Are you required to file a New Hampshire Legacy and Succession Tax return (see instructions)?
YES
NO
NH Tax
Are you required to file a New Hampshire Estate Tax return (see instructions)?
YES
NO
Obligation
Under penalties of perjury, I declare that I have examined this report and to the best of my belief it is true, correct and complete. If prepared
STEP 5
by a person other than the trustee, this declaration is based on all information of which the preparer has knowledge.
Signatures
FOR DRA USE ONLY
SIGNATURE OF TRUSTEE OR SUCCESSOR TRUSTEE
DATE
SIGNATURE OF PAID PREPARER IF OTHER THAN SUCCESSOR TRUSTEE
DATE
PREPARER'S TAX IDENTIFICATION NUMBER
PREPARER'S ADDRESS
NH DEPT OF REVENUE ADMINISTRATION
AUDIT DIVISION
MAIL
PO BOX 457
TO:
CITY/TOWN, STATE & ZIP CODE
CONCORD NH 03302-0457
AU-101-C
Rev. 12/00
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