Form Ht-209 - Employe Death Benefit Report - Wisconsin Department Of Revenue
ADVERTISEMENT
1Employe Death Benefit Report
WISCONSIN DEPARTMENT OF REVENUE
PO Box 8906
For deaths after 12-31-91
Madison, WI 53708-8906
Telephone (608) 266-2772
1. Name of payor reporting
2. Name of plan
3. Name of deceased employe or former employe
4. Date of death
5. Address of decedent
6. Type of payment reported (check only one)
Death benefit
Other (explain below)
Annuity
Profit sharing
Wage Continuation
Deferred compensation
Pension
Bonus
7. Amount of payment if paid in one sum
Date of payment
8. If payment will be made by installments, state number and amount of installments, age of beneficiary, mortality table and rate of interest used in
determining the value of the installments as of date of death.
Indicate value as of date of death
9. Names and addresses of beneficiaries
Relationship to decedent
Share of benefits payable
10. THE BENEFITS REPORTED ABOVE ARE PAYABLE UNDER A FEDERALLY
PLAN
QUALIFIED
NON-QUALIFIED
11. If the decedent contributed to the plan or toward the benefits reported on this form, please provide the following:
contributions by decedent $
contributions by employer to decedent's account $
CERTIFICATION
As representative of the payor named above, I certify that the information contained in this report is correct to the best of my knowledge and belief.
Signature
Title
Date
IRA or HR 10 Plan — This form does not have to be completed to report payments from an IRA or HR 10 Plan.
Section 72.34, Wisconsin Statutes provides that every person liable for paying benefits to the estate or a beneficiary of a deceased employe or former
employe in the form of an annuity, bonus, pension or other benefit under a retirement, deferred compensation or profit-sharing plan taxable under this
chapter, directly or through a trust or fund created by the employer for such purpose, shall give notice of such obligation to the department within 30
days following the date of payment, or the date of the initial payment if more than one payment is forthcoming, to the estate or any beneficiary of such
employe or former employe.
HT-209 (R. 6-09)
Wisconsin Department of Revenue
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial