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Date of Transfer HOLDING INSTITUTION OR TRANSFER AGENT Name Address City State Zip Code Signature of Authorized Offi cial (Phone) This notice must be provided to the county assessor of the county in which the resident decedent was domiciled at the time of death, or to the Indiana Department of Revenue. Prescribed by the Indiana Department of Revenue Form IH-19 State Form 48837 (R2 / 04-07) NOTICE OF INTENDED TRANSFER OF CHECKING ACCOUNT Name of Decedent Social Security Number Address County of Residence Date of Death (if known) Under Code § 6-4.1-8-4.6, notice is hereby served that the checking account of the decedent qualifying under said statute, in the possession or control of the undersigned, has been transferred to an individual other than the surviving spouse and the following information is given concerning such property: Description of Property Account Number Form of Ownership Fair Market Value at Date of Death Name of Transferee(s) Relationship to Decedent Phone Number of Transferee(s) Address of Transferee(s) NOTE: (If you will enclose a self-addressed, stamped envelope and two copies of this Notice, one will be returned to you stamped with the date it is re- ceived and the name of the offi ce receiving it.)