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Not for Public Access* AFFIDAVIT OF NO INHERITANCE TAX DUE STATE OF INDIANA ) IN THE COURT ) SS: COUNTY OF ) CAUSE NO. In the Matter of the Estate of: , deceased. Address of Decedent: County of Decedent’s Residence: Social Security Number of Decedent: Date of Decedent’s Death: I, (name of affi ant), being duly sworn upon my oath, state that: I am familiar with the facts set out in this affidavit as the (state relationship of affi ant to Decedent or Decedent’s estate) of Decedent or Decedent’s estate. No inheritance tax is due by reason of Decedent’s death, because no transferee receives taxable transfers in excess of such transferee’s exemption from inheritance tax as listed herein. Following is a complete listing of all transfers subject to inheritance tax by reason of Decedent’s death (attach additional pages as necessary): Description of Property Manner of Transfer Date of Death Value Total Value of All Taxable Transfers by Decedent (Gross estate) Less total expenses of decedent/estate** Taxable estate * Once completed, this form is confi dential pursuant to Ind. Code § 6-4.1-12-12. To comply with Trial Rule 5(G) this form is marked “Not for Public Access” and is required to be fi led on light green paper if it is fi led for an otherwise public estate. Attach an itemized list of deductions. See, Ind. Code § 6-4.1-3-13. IH-Exem State Form 48831 (R3 / 4-09) ---PAGE BREAK--- Following is a complete listing of the transferees of Decedent’s taxable transfers and the value of such transfers (attach additional pages as necessary): Name of Transferee Relationship to Decedent Value of Transfer(s) Exemption Total Value of All Taxable Transfers by Decedent Dated: Signature: Name of Lawyer: Printed: Address: Address: Telephone: STATE OF INDIANA ) ) SS: COUNTY OF ) Before me, a Notary Public in and for County, State of , personally appeared , who acknowledged execution of the foregoing document and who, being duly sworn, stated the representations contained herein to be true. WITNESS my hand and Notarial Seal this of , . (Signature) (Printed) Notary Public SEAL My commission expires: Not for Public Access* ---PAGE BREAK--- Instructions for Use of Affi davit of No Inheritance Tax Due This form is prescribed under Ind. Code § 6-4.1-4-0.5. It may be used to state that no inheritance tax is due as a result of Decedent’s death after application of the exemptions provided by Ind. Code § 6-4.1-3,et seq. The affi davit may be used only for a decedent whose taxable transfers to each transferee are less than that transferee’s exemptions. If transfers to any transferee exceed that transferee’s exemption, this affi davit is not available. All of the property transferred by the Decedent by taxable transfers should be included in the list of taxable transfers herein with the property described, with the nature of the transfer described, and with the date of death value of the transferred property listed. If real property transfers are included, the legal description of the property should be included. Use attachments if necessary for such descriptions. Each recipient of taxable transfers by Decedent should be listed by name with the transferee’s relationship to Decedent, the total value of property transferred by Decedent to him or her, and the amount of the transferee’s exemption. Allowable exemptions are unlimited for Decedent’s surviving spouse and for qualifi ed charitable entities. See Ind. Code 6-4.1-3-10 through 6-4.1-3-12 for specifi c exemption amounts. If real estate is included in the property subject to taxable transfers by Decedent, the affi davit may be recorded in the offi ce of the county recorder. The affi davit must include the legal description of such real property to be so recorded. The SSN must be redacted in order to be recorded. If Ind. Code § 6-4.1-8-4 requires consent to transfer personal property listed on this affi davit, the affi davit may be submitted to the county assessor to establish that consenting to such transfer will not jeopardize collection of inheritance tax. Recording this affi davit with the county recorder will terminate the statutory lien on such real estate for inheritance tax. Similarly, submission of the affi davit to the county assessor in the Decedent’s county of residence discharges the lien on personal property for inheritance tax. Such liens may be reattached if the department obtains an order that inheritance tax is owed.