Indiana Indiana Inheritance Tax Return for Non-Resident Decedent

Indiana Inheritance Tax Return for Non-Resident Decedent
Form IH-12
Form IH-12
SF # 51492
(R2/08-07)

Prescribed by the Indiana Department of State Revenue

indiana inheritance tax return
for a non-resident decedent

note: Please read carefully the general instructions before preparing this return.
1. Decedent’s name	

2. Business or occupation	

4. Decedent’s residence (domicile) at time of death	
	

3. Date of death

5. Social Security number

	

6. Address of decedent at time of death	

7. Did the decedent die testate?	
If yes, attach copy of will

YES	NO



8. Name of ancillary administrator or executor	

9. Address of ancillary administrator or executor

10. Location of court	
11. Gross value of entire estate, wherever situated: Amount $
	
Is a Federal Estate Tax Return required to be filed with the IRS?  YES       NO


	
If yes, attach a copy
Name, address and phone number of attorneys representing estate

Schedule A attached hereto discloses all interests of decedent in Indiana real estate and sets forth the information called for
in the heading of said schedule.
Schedule B attached hereto discloses all tangible personal property of decedent which had an actual situs in this state, as
called for in the heading of said schedule.
Schedule C attached hereto discloses all information respecting gifts, transfers and trusts as called for in the heading of said
schedule.
Schedule D attached hereto sets forth all allowable deductions in connection with the settlement of the non-resident decedent’s
estate in Indiana.
Schedule E attached hereto discloses the requested information concerning the persons beneficially interested in the property
taxable in this state.
I have made a due and diligent search for property of every kind, nature and description left by the decedent within the
jurisdiction of this state and have been able to discover only that set forth in Schedules A, B and C. No information of any
other property of the decedent has come to my knowledge, and I verily believe that the decedent left no property except as
therein set forth herein.
											

(Signature)

											
								

		

	

(Capacity)
(Address)



STATE OF INDIANA		
	
					
COUNTY OF _______________	

)
) SS:
)

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 _______ day of ________________, ___________.
							
							
(Signature) _________________________________
							
							
(Printed) ___________________________________
											Notary Public

SEAL

My commission expires: ___________________



schedule a
real estate
	

Did the decedent, at the time of his or her death, own any real estate in Indiana? 	YES		NO



			
Description			No. of Acres			
											
										
	

						

total schedule a

Fair Market
Value at Date
of Death

schedule b
tangible personal property
Did the decedent, at the time of his or her death, own tangible personal property that has an actual situs in this state?
											
				
				

YES		NO



							Fair Market Value
Description						
at Date of Death

						

total schedule b

schedule c
transfers during decedent’s life
Did the decedent, at any time during his or her life, make any transfers in contemplation of death? See Ind. Code § 6-4.1-2-4.						

YES		NO



Did the decedent, within one (1) year immediately preceding his or her death,
make any transfers of property for less than an adequate and full consideration
in money or money’s worth?								

YES		NO



Did the decedent, at any time during his or her life, make a transfer of property
for less than an adequate and full consideration in money or money’s worth in
which he or she retained a life estate, the right to income or some other interest?		

YES		NO



At the time of decedent’s death, were there any trusts in existence, created by
the decedent or others, in which the decedent held an interest? If yes, attach copy of
the trust(s)?										

YES		NO



NOTE: If any transfers made within one (1) year immediately preceding the decedent’s death for less than an adequate
and full consideration are claimed not to have been made in contemplation of death, submit enough proof to overcome
the presumption outlined by Ind. Code § 6-4.1-2-4.
If any of the above are answered “YES” describe below.

Date of Transfer,
Description of Property Transferred
and Means of Transfer

					TOTAL SCHEDULE C

Fair Market Value
at Date of Death
Less Consideration
Received

schedule d
deductions
	

List only deductions claimed and allowed against the property taxable in this state.

	
		

Nature and Description of Deductions Claimed		Amount of Deductions Claimed

total schedule d
recapitulation
											
				

SCHEDULE A

				

SCHEDULE B

				

SCHEDULE C

				TOTAL
				

LESS DEDUCTIONS (SCHEDULE D)

				TOTAL TAXABLE ESTATE

Total taxable assets

SCHEDULE E
PERSONS BENEFICIALLY INTERESTED IN THIS ESTATE
On Schedule E list only the persons beneficially interested in the property taxable in this state, showing the value of interests received by those persons in the Indiana property.
List the name, address, and relationship to decedent, and whether such relationship is by blood, marriage, or adoption,
of each transferee entitled to share in the estate or who received property, the transfer of which is taxable under the
Inheritance Tax Law, I.C. 6-4.1. If the decedent died testate list the section of the will applicable to each testamentary
transfer.
List in the appropriate column the age of each transferee, the value of property transferred, the exemption, and the amount
of the transfer subject to tax.
Name, Address, Relationship
of Transferee to Decedent
and Applicable Section of Will,
If Any

Age

TOtal value of property transferred

Value of Property
Transferred

Exemption

Amount
Subject
to Tax

inheritance tax computation

												Name of Decedent
Name and Address of Beneficiary	

Relationship and Date of Birth	

Value of Interest	

Exemption	

1.

											Total Tax

Amount of Tax