Nebraska State Court Form REQUIRED CERTIFICATE OF MAILING A NOTICE OF FILING A PETITION FOR THE DETERMINATION OF INHERITANCE TAX CC 15:5 New 02/2016 Neb. Rev. Stat. §77-2018.02(6) IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA In the Matter of the Estate of: Case #____________________ _________________________________ (Decedent) CERTIFICATE OF MAILING A NOTICE OF FILING A PETITION FOR THE DETERMINATION OF INHERITANCE TAX I/We, , swear or affirm, under the penalties of perjury, that on the day of , 20 _ , pursuant to Neb. Rev. Stat. §77-2018.02(6), I mailed a notice informing the Nebraska Department of Health and Human Services that I/We have filed a petition for the determination of inheritance tax in the above stated matter. This notice was sent by first class mail, postage prepaid. _______________________________________ Signature of Petitioner(s) _______________________________________ Print or Type Name _______________________________________ Bar Number and Firm Name (attorneys only) _______________________________________ Phone Date______________________________________ __________________________________________ Street Address/P.O. Box __________________________________________ City/State/ZIP Code of __________________________________________ E-mail Address Page 1 of 1 Certificate of Mailing a Notice of Filing A Petition for the Determination of Inheritance Tax CC 15:5 New 02/16 American LegalNet, Inc. www.FormsWorkFlow.com