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)  American LegalNet, Inc. www.FormsWorkflow.com 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: ___________________  American LegalNet, Inc. www.FormsWorkflow.com 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 Fair Market Value at Date of Death total schedule a American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 Fair Market Value at Date of Death Less Consideration Received TOTAL SCHEDULE C American LegalNet, Inc. www.FormsWorkflow.com 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 Total taxable assets SCHEDULE C TOTAL LESS DEDUCTIONS (SCHEDULE D) TOTAL TAXABLE ESTATE American LegalNet, Inc. www.FormsWorkflow.com 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 Value of Property Transferred Exemption Amount Subject to Tax TOtal value of property transferred American LegalNet, Inc. www.FormsWorkflow.com inheritance tax computation Name of Decedent Name and Address of Beneficiary Relationship and Date of Birth Value of Interest Exemption Amount of Tax 1. Total Tax American LegalNet, Inc. www.FormsWorkflow.com general instructions for preparation of form ih-12 revised 2004 I. Property subject to taxation The inheritance tax is imposed and levied upon all real and tangible personal property within the jurisdiction of this state owned by non-resident decedents. The words real or personal property within the jurisdiction of this state, as used in the Indiana Inheritance Tax Law, include all real and tangible personal property that has a situs in the state. II. definition of transfer The word “transfer”, as contemplated by the “Death Taxes” Article of Indiana Code, includes the passing of property or any interest therein in possession or enjoyment, present or future, by inheritance, descent, devise, bequest, grant, bargain or gift. The exercise of the right of survivorship in cases of joint ownership is deemed a taxable transfer in the same manner as though the whole property belonged absolutely to the deceased joint owner and had been devised or bequeathed to the survivor or survivors by will. III. Deductions Indiana Code § 6-4.1-3-15 states, “The following items, and no others, may be deducted from the value of property interests transferred by a non-resident decedent: (1) taxes, other than federal estate taxes; (2) those administration expenses described in section 13(b)(9) of this chapter; (3) liens against the property so transferred; and (4) claims against the decedent’s domiciliary estate which are allowed by the court having jurisdiction over that estate and which will not be paid from that estate because it is exhausted.” Indiana Code § 6-4.1-3-13(b)(9) allows “expenses incurred in administering property subject to inheritance tax; including but not limited to reasonable attorney fees, personal representative fees, and trustee fees.” IV. Supplemental documents If any of the following documents exist, each must be supplied with every copy of the return filed: will and codicils of decedent, renunciations, trust agreements, proof of surviving joint tenants’ contributions, and statements of the net earnings or operating results and balance sheets of closely held corporations. If the estate is required to file a federal estate tax return (Form 706), a copy of the return as filed with the federal government must be filed with the Indiana Department of State Revenue. After the receipt of the final determination of federal estate tax closing letter from the Internal Revenue Service or of the final judgment of any court having jurisdiction, confirming, increasing or reducing the federal estate tax shown to be due on the return, a copy thereof shall be filed within thirty (30) days with the Department of State Revenue. V. Valuation Unless otherwise provided, all property taxable must be valued at the fair market value as of the date of decedent’s death. For each parcel of real estate in the state of Indiana which the decedent died seized or possessed, or in which the decedent had any right, title or interest at the time of death, an appraisal report made by a licensed appraiser must be submitted. If incorrect values are set out in the schedules, the inheritance tax proceedings shall necessarily be delayed until further evidence of value can be obtained. VI. Payment of tax The inheritance tax becomes due and payable at the time (date) of decedent’s death. A discount of 5% shall be allowed on all payments of tax made within nine (9) months from date of death. If the tax or any portion thereof is not paid within one (1) year after its accrual, interest on the unpaid portion shall be charged at the rate of 10% per annum, except in those cases where for unavoidable cause of delay in determining the tax the Department has reduced the interest to 6% per annum from the date of decedent’s death until date of payment. Payment should be made directly to the Inheritance Tax Section of the Indiana Department of State Revenue, 100 N. Senate Avenue, Room N248, Indianapolis, Indiana 46204-2253. Checks should be made payable to the Indiana Department of State Revenue. note: Any requests for forms necessary for the execution of a non-resident inheritance tax return, and question(s) related to such return, may be directed to the aforementioned address or by, telephone at (317) 232-2154. American LegalNet, Inc. www.FormsWorkflow.com