Schedule I Form 101 - Annuities & Employe Death Benefits

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I
SCHEDULE
ANNUITIES & EMPLOYE DEATH BENEFITS
FORM 101
Page
of
Estate of:
I
of Schedule
No
Yes
1 a. Was the decedent, immediately before death, receiving any annuity?
b. If “yes”, did annuity cease at death?
c. If a. is “yes”, was that annuity paid pursuant to a federally qualified plan?
2. If the decedent was employed at the time of death, did an annuity or other payment become payable to any
beneficiary by reason of the beneficiary’s having survived the decedent?
3 a. Did a benefit under an individual retirement account become payable to any beneficiary?
b. If “yes”, is an annuity payable to the beneficiary for life or for at least 36 months following decedent’s death?
4 a. Is the beneficiary electing to waive favorable federal income tax treatment of a lump-sum distribution from a
federally qualified plan?
b. If “yes”, attach a copy of the written election made by each beneficiary. Include the name, social security
number and address of each electing beneficiary.
Item No.
Description - See instructions
Value at Date of Death
Section a. - Annuities & Employe Death Benefits Payable to
Spousal Rights
Payable to Estate
the Estate
1.
$
$
TOTAL - Enter at Item No. 1 of Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Section b. - Annuities & Employe Death Benefits Payable to
Spousal Rights
Payable to Beneficiary
Named Beneficiaries
$
$
1.
$
TOTAL - Enter on line 21 of page 2, Form 101 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HT-023 (R. 1-01)
Wisconsin Department of Revenue

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