City and County of San Francisco City Hall, Room 190 1 Dr. Carlton B. Goodlett Place San Francisco, CA 94120 STATEMENT OF DEATH OF REAL PROPERTY OWNER IMPORTANT NOTICE Section 480(b) of the Revenue and Taxation Code requires that the personal representative file this statement with the Assessor in each county where the decedent owned real property at the time of death. File a separate statement for each parcel of real property owned by the decedent in the City and County of San Francisco. This notice is a written request from the Office of the Assessor for a Change in Ownership Statement. Failure to file this statement results in the assessment of a penalty. This statement will be held secret as required by Section 481 of the Revenue and Taxation Code. The property may be subject to a supplemental assessment in an amount to be determined by the City and County of San Francisco Assessor - Recorder Office. For further information please call the Real Property Division at (415) 554-5596. Estate of: Deceased Probate No.: 1. 2. Date of Death: 3. Address of Real Property: 4. Heirs/Devisees of Subject Property and Relationship to the Decedent: Name Relationship 5. If any additional Property taxes are due, they will be billed to the Heirs/Devisees at: Percentage of Property Each Will Receive Name: Address: City: State: 6. Is this property to be sold out of the estate? Zip Code: ( ) Yes ( ) No The office of the Assessor may contact you for additional information regarding this transaction. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing and all information hereon, including any accompanying statements or documents, is true correct and complete to the best of my knowledge and belief. Signature of ( Date: ) Executor/Administrator ( )Attorney Please Print Name Day time telephone number: American LegalNet, Inc. www.FormsWorkflow.com