Form Rv-F1403601 - Deceased Depositor Report
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1TENNESSEE DEPARTMENT OF REVENUE
DECEASED DEPOSITOR REPORT
Date
TO: Inheritance Tax Unit
Director of Audit Division
Andrew Jackson State Office Building
Nashville, Tennessee 37242
In accordance with Section 67-8-417, Tennessee Code Annotated, the following report is made.
1.
Name of Deceased Depositor:
Address:
ACCOUNT
TYPE OF
ACCOUNT
2.
NUMBER
ACCOUNT
BALANCE
____________________
____________________
___________________
____________________
____________________
___________________
____________________
____________________
___________________
____________________
____________________
___________________
3.
Payable or transferred to:
Address:
4.
Safety Deposit Box: Yes
Number
No
Copy of inventory included
or to be furnished
.
5.
Notes or bills for collection described:
Maker:
Date of Note/Bill:
Balance:
By:
Title
Name of Bank or Federal Savings & Loan
Address
City, State, Zip Code
RV-F1403601 (Rev. 10-01)
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