Notice Of Escheat Property Form

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State of Washington
NOTICE OF ESCHEAT PROPERTY
Department of Revenue
Miscellaneous Tax Division
County ___________________________
PO Box 47488
Olympia, WA 98504-7488
Probate ___________________________
Notice is hereby given pursuant to Chapter 11.08 RCW, that the decedent named below is not survived by any person
appearing to be entitled to the estate under the laws of this state, and that the estate therefore constitutes escheat property
subject to the provisions of Chapter 11.08 RCW.
Under the provisions of RCW 11.28.120(5)(a), the Director of the Washington State Department of Revenue, or the Director’s
designee, has the right to serve as personal representative of such escheat estate.
General Questionnaire:
Please answer all questions to the best of your knowledge.
Name of decedent _________________________________________ _________________________________ ________
(Last)
(First)
(Initial)
Address ____________________________________________ _________________________ ________ __________
(Street)
(City)
(State)
(Zip Code)
Date of death ______________________ County ____________________________
I.
ASSETS: Nature and location of Washington estate.
A. Intangibles (bank accounts, cash, stock, bonds, etc.) – Use additional sheets if necessary.
Value
Location (bank branch, etc.)
_______________________________
___________________________________________________
_______________________________
___________________________________________________
_______________________________
___________________________________________________
B. Washington real property (legal description and assessed value)
_____________________________________________________________________________________________
C. Personal effects (description and location) ________________________________________________________
II. DEBTS: To the best of my knowledge the debts of the estate are as follows:
A. Funeral ___________________________________________________________________________________
B. Last illness ________________________________________________________________________________
C. Others (describe) ____________________________________________________________________________
My interest in this estate is as a
creditor or
an interested party other than a creditor. (describe below).
Signed ________________________________________________
Please print the following:
Name _________________________________________________
Address _______________________________________________
________________________________________________
Phone (_____) ____________________________
Email ___________________________________
Please complete and mail this form to:
Washington State Department of Revenue
Estate Tax Section
P.O. Box 47488
Olympia, WA 98504-7488
For tax assistance visit or call (360) 570-3265, option 2. To request this document in an alternate format call
1-800-647-7706. Teletype (TTY) users may call (360) 705-6718.
REV 85 0030 (6/22/11)

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