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Irs gov tax forms 2013 2019 926 Household Employer s Tax Guide for how to correct that form. For more information see Treasury Decision 9405 at www.irs.gov/irb/2008-32IRB/ar13. html. Return to correct Form 1120 or 1120-A as originally filed or as Cat. No. 11200I later adjusted by an amended return a claim for refund or an examination or to make certain elections after the prescribed deadline see Regulations sections 301. 9100-1 through -3. Use Form 720X Amended Quarterly Federal Excise Tax Return to make adjustments to liability reported on Forms 720 you have filed for previous quarters. Effective August 28 2014 if you are filing Form 843 in response to Letter 5067C Annual Fee on Health Insurance Providers Final fee note that the following address is being added to the Where To File table on page 2 of the Instructions for Form 843 Rev* December 2013. The address to mail Form 843 in this case is Internal Revenue Service Mail Stop 4921 IPF 1973 N* Rulon White Blvd. Ogden UT 84404 The above address is effective ONLY if you are filing Form 843 in response to Letter 5067C Annual Fee on Health Insurance Providers Final Fee. Please see the modifications to the Where to File table below. Where To File IF you are filing Form 843 THEN mail the form to In response to an IRS notice regarding a tax or fee related to certain taxes such as income employment gift estate excise etc* The address shown in the notice. For penalties or for any other reason other than an IRS notice see above or Letter 4658 or 5067C see below The service center where you would be required to file a current year tax return for the tax to which your claim or request relates. See the instructions for the return you are filing. of Branded Prescription Drug Fee Note. To ensure proper processing write Branded Prescription Drug Fee across the top of Form 843. Caution* Use this address only if you are claiming a refund of the branded prescription drug fee. Fee on Health Insurance Providers Final Fee Health Insurance Providers across the For requests of a net interest rate of zero the health insurance provider your most recent return* This change will be reflected in the next revision of the Instructions for Form 843. Instructions for Form 843 Rev* December 2013 Department of the Treasury For use with Form 843 Rev* August 2011 Claim for Refund and Request for Abatement Section references are to the Internal Revenue Code unless otherwise noted* A refund of a branded prescription drug fee. If you received an IRS notice notifying you of a change to an item on your tax return or that you owe interest a penalty or addition to tax follow the instructions on the notice. You may not have to file Form 843. General Instructions Future Developments TIP For the latest information about developments related to Form 843 and its instructions such as legislation enacted after they were published go to www*irs*gov/form843. Purpose of Form Use Form 843 to claim a refund or request an abatement of certain taxes interest penalties fees and additions to tax.

8880 form 2018 2019 Credits from lines 46 and 47. 3. Subtract line 2 from line 1. Also enter this amount on Form 8880 line 11. Cat. No. 33394D Form 8880 2018 Page 2 General Instructions Section references are to the Internal Revenue Code. Use Form 8880 to figure the amount if any of your retirement savings designated Roth account. TIP This credit can be claimed in addition to any IRA deduction claimed on Schedule 1 Form 1040 line 32 or Form 1040NR line 32. What s New Designated beneficiary Achieving a Better Life Experience ABLE account contributions. Beginning in 2018 as part of a provision contained in the Tax Cuts and Jobs Act of 2017 a retirement savings contribution credit may be claimed for the amount of contributions you make before January 1 2026 to an ABLE account of which you are the Disabilities for more information. Future Developments For the latest information about developments related to Form 8880 and Note. Form Credit for Qualified Retirement Savings Contributions Department of the Treasury Internal Revenue Service Attach to Form 1040 or Form 1040NR. Go to www.irs.gov/Form8880 for the latest information. CAUTION Attachment Sequence No. 54 Your social security number Name s shown on return OMB No. 1545-0074 You cannot take this credit if either of the following applies. Specific Instructions Column b Complete column b only if you re filing a joint return. Line 2 Include on line 2 any of the following amounts. SIMPLE plan. Voluntary employee contributions to a qualified retirement plan as Contributions to a 501 c 18 D plan. These amounts may be shown in box 12 of your Form s W-2 for 2018. 401 k 403 b governmental 457 b 501 c 18 D SEP or SIMPLE plans. Qualified retirement plans as defined in section 4974 c including the federal Thrift Savings Plan. Don t include any of the following. Purpose of Form Distributions not taxable as the result of a rollover or a trustee-totrustee transfer. SIMPLE plan. Voluntary employee contributions to a qualified retirement plan as Contributions to a 501 c 18 D plan. These amounts may be shown in box 12 of your Form s W-2 for 2018. 2. Form 1040 filers Enter the total of your credits from Schedule 3 lines 48 through 50 and Schedule R line 22. The amount on Form 1040 line 7 or Form 1040NR line 36 is more than 31 500 47 250 if head of household 63 000 if married filing jointly. The person s who made the qualified contribution or elective deferral a was born after January 1 2001 b is claimed as a dependent on someone else s 2018 tax return or c was a student see instructions. a You Traditional and Roth IRA contributions and ABLE account contributions by the designated beneficiary for 2018. Do not include rollover contributions. Elective deferrals to a 401 k or other qualified employer plan voluntary employee contributions and 501 c 18 D plan contributions for 2018 see instructions. Add lines 1 and 2. Certain distributions received after 2015 and before the due date including extensions of your 2018 tax return see instructions.

Form os 114 2018 2019 Form OS-114 must be filed and paid on or before the last day of the month following the end of the period. CT Tax Registration All quarterly and monthly filers must file Form OS-114 and pay its associated taxes electronically. Form OS-114 SUT Department of Revenue Services PO Box 5030 Hartford CT 06102-5030 Rev. 12/18 OS114 0718W 01 9999 Connecticut Sales and Use Tax Return See Form O-88 Instructions for Form OS-114 Connecticut Sales and Use Tax Return. Type or print. Complete the return in blue or black ink only. Date electronically Telephone number M M - D D - Y Y Y Y paper tax return to DRS. Paid preparer s address Form OS-114 Page 2 Rev. 12/18 See instructions Form O-88 before completing. Do not use grayed-out fields. For period ending Due date Connecticut Tax Registration Number M - D Y Federal Employer Identification Number Taxpayer Name This return MUST be filed electronically Address Number and street apartment number PO Box DO NOT MAIL paper tax return to DRS. City town or post office ZIP code State If applicable provide the following information Check here if this is an amended return. Final Return Enter last business date Rounding You must round off cents to the nearest whole dollar on your return and schedules. Column 1 6. 35 Tax Rate 1. Gross receipts from sales of goods. 1. 4. Goods purchased by your business subject to use tax. 4. 5. Leases and rentals by your business subject to use tax. 5. 6. Services purchased by your business subject to use tax. Do not use grayed-out fields. For period ending Due date Connecticut Tax Registration Number M - D Y Federal Employer Identification Number Taxpayer Name This return MUST be filed electronically Address Number and street apartment number PO Box DO NOT MAIL paper tax return to DRS* City town or post office ZIP code State If applicable provide the following information Check here if this is an amended return* Final Return Enter last business date Rounding You must round off cents to the nearest whole dollar on your return and schedules. Column 1 6. 35 Tax Rate 1. Gross receipts from sales of goods. 1. 4. Goods purchased by your business subject to use tax. 4. 5. Leases and rentals by your business subject to use tax. 5. 6. Services purchased by your business subject to use tax. 6. 7. Total Add Lines 1 through 6. 7. 8. Deductions. See instructions. 8. 9. Subtract Line 8 from Line 7. If zero or less enter 0. 9. 10a* Amount of tax due Multiply Line 9 by Tax Rate. 10a* 10. Total tax due Add Line 10a Columns 1 2 and 3. 10. 11. For amended return only enter tax paid on prior return*. 11. 12. Net amount of tax due Subtract Line 11 from Line 10. 12. 13. Interest 14. Total amount due Add Line 12 and Line 13. 14. Penalty Declaration I declare under the penalty of law that I have examined this return including any accompanying schedules and statements and to the best of my knowledge and belief it is true complete and correct. I understand the penalty for willfully delivering a false return or document to the Department of Revenue Services DRS is a fine of not more than 5 000 imprisonment for not more than five years or both.

State of hawaii tax form g 45... 30. Amended Returns add lines 30 and 31. 32. 33. PLEASE ENTER THE AMOUNT OF YOUR PAYMENT. Attach a check or money order payable to HAWAII STATE TAX COLLECTOR in U.S. dollars to Form G-45. FORM G-45 STATE OF HAWAII DEPARTMENT OF TAXATION DO NOT WRITE IN THIS AREA Rev. 2017 GENERAL EXCISE/USE TAX RETURN Fill in this oval ONLY if this is an AMENDED return / PERIOD ENDING mm/yy Last 4 digits of your FEIN or SSN HAWAII TAX I. SIGNATURE G45I 2017A 01 TITLE DATE DAYTIME PHONE NUMBER Continued on page 2 Parts V VI MUST be completed Form G-45 Page 2 of 2 Name Hawaii Tax I. D. NO. GE NAME Column a BUSINESS VALUES GROSS PROCEEDS ACTIVITIES OR GROSS INCOME EXEMPTIONS/DEDUCTIONS TAXABLE INCOME Attach Schedule GE Column a minus Column b PART I - GENERAL EXCISE and USE TAXES OF 1. 005 ATTACH CHECK OR MONEY ORDER HERE 1. Wholesaling 2. Manufacturing 3. Producing 4. Wholesale Services 5. Landed Value of Imports for Resale 6. Business Activities of Disabled Persons 7. Sum of Part I Column c Taxable Income Enter the result here and on page 2 line 21 Column a 8. Retailing 9. Services Including Professional 10. Contracting 11. Theater Amusement and Broadcasting 12. Commissions 13. Transient Accommodations Rentals 14. Other Rentals 15. Interest and All Others for Consumption DECLARATION - I declare under the penalties set forth in section 231-36 HRS that this return including any accompanying schedules or statements has been examined by me and to the best of my knowledge and belief is a true correct and complete return made in good faith for the tax period stated pursuant to the General Excise and Use Tax Laws and the rules issued thereunder. IN THE CASE OF A CORPORATION OR PARTNERSHIP THIS RETURN MUST BE SIGNED BY AN OFFICER PARTNER OR MEMBER OR DULY AUTHORIZED AGENT. D. No* PART III - INSURANCE COMMISSIONS. 15. 0015. 00. 00. 00 18. Insurance Enter this amount on line 23 Column a PART IV - CITY COUNTY OF HONOLULU SURCHARGE TAX OF 1. 005 19. Oahu Surcharge PART V SCHEDULE OF ASSIGNMENT OF TAXES BY DISTRICT ALL taxpayers MUST complete this Part and may be subject to a 10 penalty for noncompliance. See Instructions. DARKEN the oval of the taxation district in which you have conducted business. IF you did business in MORE THAN ONE district darken the oval MULTI and attach Form G-75. Oahu Maui PART VI - TOTAL PERIODIC RETURN 21. Enter the amount from Part I line 7. Hawaii Kauai TAX RATE TOTAL TAX Column c Column a X Column b x. 005 x. 04 25. TOTAL TAXES DUE* Add column c of lines 21 through 24 and enter result here but not less than zero. If you did not have any activity for the period enter 0. 00 here. 25. PENALTY 26. Amounts Assessed During the Period. INTEREST 26. For Amended Return ONLY TOTAL AMOUNT. Add lines 25 and 26. 27. 28. TOTAL PAYMENTS MADE FOR THE PERIOD For Amended Return ONLY. 28. 29. CREDIT TO BE REFUNDED. Line 28 minus line 27 For Amended Return ONLY. 29. 30. ADDITIONAL TAXES DUE* Line 27 minus line 28 For Amended Return ONLY. Write the filing period and your Hawaii Tax I. D. No* on your check or money order. Mail to HAWAII DEPARTMENT OF TAXATION P.

Fae 170 2017 2019 form RVR0011001 (10/17)TENNESSEE DEPARTMENT OF REVENUE Franchise and Excise Tax ReturnFAE 170Tax Year BeginningAccount NumberTax Year EndingFEINNAICSSOS Control NumberCheck all that apply: Amended return Final

Form 104 2018 2019 Additions to Federal Taxable Income 2. State Addback enter the state income tax deduction from your federal form 1040 schedule A line 5a see instructions 3. Other Additions explain see instructions Explain Name 4. Subtotal sum of lines 1 through 3 5. Subtractions from the DR 0104AD Schedule line 18 you must submit the DR 0104AD schedule with your return. 6. Colorado Taxable Income subtract line 5 from line 4 Tax Prepayments and Credits full-year residents use DR 0104CR and part-year and nonresidents use DR 0104PN 7. 180104 19999 DR 0104 09/17/18 COLORADO DEPARTMENT OF REVENUE Colorado. gov/Tax 2018 Colorado Individual Income Tax Return Full-Year Part-Year or Nonresident or resident part-year non-resident combination Must attach DR 0104PN Your Last Name Date of Birth MM/DD/YYYY Your First Name SSN Enter the following information from your current driver license or state identification card. If Joint Spouse s Last Name Spouse s Date of Birth MM/DD/YYYY Mark if Abroad on due date see instructions Deceased State of Issue Middle Initial If checked and claiming a refund you must submit the DR 0102 with your return* Last 4 characters of ID number Date of Issuance Spouse s First Name Spouse s SSN current driver license or state identification card. Mailing Address City Phone Number State Zip Code Foreign Country if applicable Round To The Next Dollar 1. Enter Federal Taxable Income from your federal income tax form 1040 line 10 1 Attach W-2s and 1099s with CO withholding here. Additions to Federal Taxable Income 2. State Addback enter the state income tax deduction from your federal form 1040 schedule A line 5a see instructions 3. Other Additions explain see instructions Explain Name 4. Subtotal sum of lines 1 through 3 5. Subtractions from the DR 0104AD Schedule line 18 you must submit the DR 0104AD schedule with your return* 6. Colorado Taxable Income subtract line 5 from line 4 Tax Prepayments and Credits full-year residents use DR 0104CR and part-year and nonresidents use DR 0104PN 7. Colorado Tax from tax table or the DR 0104PN line 36 you must submit the DR 0104PN with your return if applicable. 8. Alternative Minimum Tax from the DR 0104AMT you must submit the DR 0104AMT with your return* 9. Recapture of prior year credits 11. Nonrefundable Credits from the DR 0104CR line 39 the sum of lines 11 and 12 cannot exceed line 10 you must submit the DR 0104CR with your return* 12. Total Nonrefundable Enterprise Zone credits used as calculated or from the DR 1366 line 87 the sum of lines 11 and 12 cannot exceed line 10 you must submit the DR 1366 with your return* 13. Net Income Tax sum of lines 11 and 12. Subtract that sum from line 10. 13 14. Use Tax reported on the DR 0104US schedule line 7 you must submit 15. Net Colorado Tax sum of lines 13 and 14 15 16. CO Income Tax Withheld from W-2s and 1099s you must submit the W-2s and/or 1099s claiming Colorado withholding with your return* 17. Prior-year Estimated Tax Carryforward 18. Estimated Tax Payments enter the sum of the quarterly payments remitted for this tax year 19.

Form inheritance tax 2015 2019 Print TENNESSEE DEPARTMENT OF REVENUE SHORT FORM INHERITANCE TAX RETURN INH Reset AMENDED RETURN INSTRUCTIONS 1. Ann. Section 67-8-316 the representative of the estate may file the Short Form-Inheritance Tax Return. In the case of resident decedent s dying between January 1 2006 and December 31 2012 the allowable exemption is 1 000 000 in 2013 the allowable exemption is 1 250 000 in 2014 the allowable exemption is 2 000 000 and in 2015 the allowable exemption is 5 000 000. GENERAL FILING REQUIREMENT The Tennessee Inheritance Tax is a tax upon the privilege of receiving property by transfer because of a decedent s death. The personal representative or person s in possession of property of the decedent is required to file a return of the estate with the Department of Revenue. 2. FILING THE SHORT FORM If the gross estate of a resident decedent is less than the single exemption allowed by Tenn. Code. GENERAL FILING REQUIREMENT The Tennessee Inheritance Tax is a tax upon the privilege of receiving property by transfer because of a decedent s death. The personal representative or person s in possession of property of the decedent is required to file a return of the estate with the Department of Revenue. 2. FILING THE SHORT FORM If the gross estate of a resident decedent is less than the single exemption allowed by Tenn* Code. In 2016 and thereafter no inheritance tax is imposed* 3. DUE DATE The return is due nine 9 months after the date of the decedent s death unless an extension of time is granted by the Department. 4. FILING Please print in blue or black ink. Mail the return to Tennessee Department of Revenue Andrew Jackson State Office Building 500 Deaderick Street Nashville TN 37242. 5. FOR ASSISTANCE Contact Taxpayer Services Division by calling in-state toll free 1-800-342-1003 or 615 253-0600. Name of Decedent Last Name First Name Social Security No* Did decedent have a will Date of Death Yes MI Age of Decedent County of TN Probate No If Yes attach a copy to the return. If spouse is deceased enter Last Name Personal Representative s Name executor etc* Last Name Address Street Mi City Return Preparer Last Name/Firm Attorney For the Estate Last Name/Firm State Zip Code Phone Please Complete in Blue or Black Ink ROUND TO THE NEAREST DOLLAR CENTS DOLLARS 1. Real Estate Total from Schedule A reverse side. 2. Personal and Miscellaneous Property Total from Schedule B reverse side. 3. Jointly-Owned Property Total from Schedule C reverse side. 4. Transfers during decedent s life Total from Schedule D reverse side. 5. Total Gross Estate Add lines 1 through 4. 6. Allowable Exemption. IF THE GROSS ESTATE Line 5 above IS LESS THAN THE EXEMPTION TOTAL Line 6 above YOU MAY USE THIS SHORT FORM. 7. TOTAL GROSS ESTATE from Line 5. 8. TOTAL DEDUCTIONS from Schedule E. 9. NET ESTATE subtract Line 8 from Line 7. Under penalties of perjury I declare this report to be true accurate and complete to the best of my knowledge. FOR OFFICE USE ONLY Signature of Personal Representative Date Acct* No* Date Received RV-R0001702 INTERNET 2-15 SCHEDULES Date of Valuation of assets check one Value of assets at date of death SCHEDULE A - REAL ESTATE Individually owned and located in Tennessee Description Location Full Value Cash Notes Mortgages Life Insurance Stocks Bonds Annuities Furnishings Automobiles Jewelry etc* Owned Individually 11.

Iowa income tax forms fillable... 2017 IA 1040 Iowa Individual Income Tax Return For fiscal year beginning ___/___ 2017 and ending ___/___ /___ Step 1: Fill in all spaces. You must fill in your Social Security Number (SSN). Your last

Ct 1040 2018 2019 form CT-1040 Complete return in blue or black ink only. For January 1 December 31 2018 or other taxable year Year Beginning Form CT-1040 Department of Revenue Services State of Connecticut Rev. 12/18 1040 1218W 01 9999 and Ending M M - D D - Y Y Y Y Filing Status - Check only one box. 19. All 2018 estimated tax payments and any overpayments applied from a prior year 20. Payments made with Form CT-1040 EXT request for extension of time to file 20a. Connecticut earned income tax credit From Schedule CT-EITC Line 16. 20a. 20b. Claim of right credit From Form CT-1040CRC Line 6. 20b. 20c. Pass-Through Entity Tax Credit From Schedule CT-PE Line 1. For all tax forms with payment PO Box 2977 Hartford CT 06104 2977 Make your check payable to For refunds and all other tax forms without payment Commissioner of Revenue Services To ensure proper posting write your SSN s optional and 2018 Form CT 1040 on your check. State Enter city or town of residence if different from above. ZIP code Check the appropriate box to identify if you Filed Form CT-1040CRC Filed Form CT-8379 Whole Dollars Only Clip check here. Do not staple. Do not send Forms W-2 or 1099. 1. Federal adjusted gross income from federal Form 1040 Line 7 2. Column C Connecticut income tax withheld 18a. 18b. 18c. 18d. 18e. 18f. 18. Total Connecticut income tax withheld Add amounts in Column C and enter here. 19. All 2018 estimated tax payments and any overpayments applied from a prior year 20. Payments made with Form CT-1040 EXT request for extension of time to file 20a. Connecticut earned income tax credit From Schedule CT-EITC Line 16. Connecticut Resident Income Tax Return Taxpayers must sign declaration on reverse side. Print your SSN name mailing address and city or town here. Single Head of household Married filing jointly Qualifying widow er with dependent child Your Social Security Number Enter spouse s name here and SSN below. Spouse s Social Security Number Check if deceased Your first name MI Last name If two last names insert a space between names. Suffix Jr. /Sr. If joint return spouse s first name Mailing address number and street apartment number suite number PO Box City town or post office If town is two words leave a space between the words. State Enter city or town of residence if different from above. ZIP code Check the appropriate box to identify if you Filed Form CT-1040CRC Filed Form CT-8379 Whole Dollars Only Clip check here. Do not staple. Do not send Forms W-2 or 1099. 1. Federal adjusted gross income from federal Form 1040 Line 7 2. Additions to federal adjusted gross income from Schedule 1 Line 38 3. Add Line 1 and Line 2. 4. Subtractions from federal adjusted gross income from Schedule 1 Line 50 5. Connecticut adjusted gross income Subtract Line 4 from Line 3. 6. Income tax from tax tables or Tax Calculation Schedule See instructions. 7. Credit for income taxes paid to qualifying jurisdictions from Schedule 2 Line 59 8. Subtract Line 7 from Line 6. If Line 7 is greater than Line 6 enter 0. 10. Add Line 8 and Line 9. 11. Credit for property taxes paid on your primary residence motor vehicle or both 13.

Bt 1 2018 2019 form Contact Licensing at 317-232-5977 for a separate application which will need to be completed and submitted with your BT-1. Now find the six-digit code assigned to this activity and enter it on all appropriate forms. The business tax application BT-1 will accommodate up to four different codes related to your business. Indiana Department of Revenue Form BT-1 Business Tax Application State Form 43760 R14 / 8-18 A separate application is required for each business location. To file this application online visit https //inbiz. Mail To Tax Administration Processing P. O. Box 6197 Indianapolis IN 46206-6197 Licensing Section 100 N. Senate Room N281 For additional information about private employment agencies Call 317 232-5977 Instructions for Completing Form BT-1 Please allow four to six weeks for processing. Purpose Form BT-1 is an application used when registering with the and Motor Vehicle Rental Excise Tax or a combination of these taxes. All government agencies should list their proper agency name. Enter the address of the ownership. Your email address is optional. Page 1 Tax Registration Line 13 Check all that apply the type of tax es you wish to register for this business location. Complete Section A and the Signature Section of the BT-1. in*gov/BOS/Home/Index Section A Taxpayer Information see instructions on page 1 Please print legibly or type the information on this application* Visit INTax. in*gov to file and pay your business taxes online. 1. Federal Identification Number FID 2. If this business is currently registered with the Department of Revenue enter your Taxpayer Identification Number TID 3. Name of contact person responsible for filing tax forms. 4. Contact person s daytime telephone number A B Ext. 5. Check only one reason for filing this application A Starting New Business B Business Under New Ownership C To Change Type of Organization D To Add Location to Existing Account E To Register for Other Type s of Tax 6. Owner name Legal name Partnership name Corporate name or Other entity name A Check if foreign address See instructions F Other 7. Business trade name or DBA and physical location This name and address is for the business location* A Check if foreign address See instructions Name B P. O. Box numbers cannot be used as a business location address. Street Address C City D State E Zip Code F County G Township H Business Location Telephone Number I J Ext. If sole owner last name first name middle initial Suffix Primary Address D Email Address I E Corporation F S Corp 8. Check the type of organization of this business A Sole Proprietor B Partnership C LLP D LP G LLC H Nonprofit I Fed Govt J Other Govt 9. Indiana Secretary of State Control See www. in*gov/sos/ for requirements. 10. All corporations answer the following questions Otherwise proceed to Question 11. A. State of Incorporation B. Date of Incorporation D. If not incorporated in Indiana enter the date authorized to do business in Indiana* 11. North American Industry Classification System NAICS Please enter a primary and any secondary code s that may apply.

Form 92a200 2016 2019 Net Estate Total Gross Estate less Total Deductions. Total Tax Due from Tax Computation Form 92A200. 92A200 6-16 Commonwealth of Kentucky DEPARTMENT OF REVENUE FOR DEPARTMENT USE ONLY KENTUCKY INHERITANCE TAX RETURN / / / Account Number Tax Requirements for use of this return This return is to be led when 1 the date of death is on or after January 1 2005 2 any assets of the estate pass to taxable bene ciaries or taxable organizations see page 4 of general information and 3 Forms 92A201 and 92A205 do not apply. Pursuant to KRS 140. 190 the bene ciaries as well as the personal representative s may be held personally liable for the tax. Decedent s Name Last First Middle Initial Social Security Number Occupation If decedent was retired at death state occupation prior to retirement. Mo Year Return Status check one Original Return Amended Return Refund Age at Death Date of Death Cause of Death HR Code Number Residence Domicile at Time of Death Number and Street City Name and Address of Executor/Administrator/Bene ciary State ZIP Code County Exec Atty Admr CPA Did the decedent have a will No Yes If Yes attach a copy of the will* Filing status of Federal Estate and Gift Tax Return for this estate check one Not Required Required enclose copy Gross Estate 1. Individually owned assets. 2. Jointly owned assets. 3. Quali ed terminable interest property and/or powers of appointment. 4. Previously taxed property. 5. Gifts and transfers. Total Gross Estate. Deductions 6. Funeral expenses. 7. Administration expenses. 8. Debts of decedent. 9. Federal estate tax paid or estimated. Total Deductions. Interest and Penalty 10. Interest for late payment see general information. 11. Late ling penalty see general information. 12. Late payment penalty see general information. 13. Total Due tax plus interest and penalties if applicable. 14. Total previously paid. 15. Balance due/Refund. Attach check payable to Kentucky State Treasurer to this return and mail to Kentucky Department of Revenue Frankfort KY 40620 Under criminal penalties I declare that this return including accompanying documents has been examined by me and is to the best of my knowledge and belief true correct and complete. Signature of Executor/Administrator/Bene ciary Date Telephone Number E-mail Address of Executor/Administrator/Bene ciary Signature of Preparer Estate of Page of Individually Owned Assets List in this schedule all items individually owned by the decedent including life insurance payable to the estate. Please review instructions on reverse side for details. Item Number Description of Property/Name of Corporation or Obligor/ Name of Bank or Debtor Accrued Rents/ Interest/Dividends of Shares Total including continuation page s enter on page 1 line 1. If additional space is needed duplicate this page and attach as a continuation page s. Fair Cash Value INSTRUCTIONS INDIVIDUALLY OWNED ASSETS All real proper ty individually owned must be lis ted in this schedule. For repor ting agricultural or horticultural land see General Information Valuation of Property Fair Cash and Agricultural* Stocks and bonds individually owned are includable in this schedule.

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