Form Rev-548 Ex - Inheritance Tax Joint Bank Account Advance Payment Worksheet

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REV-548 EX (12-03)
INHERITANCE TAX JOINT BANK ACCOUNT
COUNTY FILE NUMBER
START
ADVANCE PAYMENT WORKSHEET
INHERITANCE TAX RECEIPT NUMBER
DECEDENT’S NAME (LAST)
(FIRST)
(MIDDLE INITIAL)
MM/DD/YYYY
DECEDENT
DECEDENT’S SOCIAL SECURITY NUMBER
DATE OF DEATH
INFORMATION
ADDRESS OF DECEDENT
CITY
STATE
ZIP
NAME OF FINANCIAL INSTITUTION
FINANCIAL
ADDRESS
CITY
STATE
ZIP
INSTITUTION
INFORMATION
TELEPHONE NUMBER
(
)
TYPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIFICATE OF DEPOSIT
OTHER ______________
ACCOUNT
MM/DD/YYYY
ACCOUNT BALANCE (INCLUDE INTEREST TO DATE OF DEATH)
ACCOUNT NUMBER
INFORMATION
ACCOUNT TITLE AS APPEARS ON SIGNATURE CARD OR CD
ORIGINAL DATE ESTABLISHED
NAME (Last)
(First)
(Middle Initial)
Department of Revenue
Use Only
PERCENT TAXABLE
ADDRESS
SURVIVING
JOINT OWNER
CITY
STATE
ZIP CODE
INFORMATION
TAX RATE
RELATIONSHIP TO DECEDENT
TELEPHONE NUMBER
(
)
NAME (Last)
(First)
(Middle Initial)
PERCENT TAXABLE
ADDRESS
SURVIVING
JOINT OWNER
CITY
STATE
ZIP CODE
INFORMATION
TAX RATE
RELATIONSHIP TO DECEDENT
TELEPHONE NUMBER
(
)
NAME (Last)
(First)
(Middle Initial)
PERCENT TAXABLE
ADDRESS
SURVIVING
JOINT OWNER
CITY
STATE
ZIP CODE
INFORMATION
TAX RATE
RELATIONSHIP TO DECEDENT
TELEPHONE NUMBER
(
)
LIST DEBTS & DEDUCTIONS BELOW
Date Paid
Payee
Description
Amount Paid
0.00
Note: Please attach to receipt
Total $ _________________
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