Transcription of Form O-71 State of New Jersey (Rev. 12-19) Division of …
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Form O-71 State of New Jersey (Rev. 12-19) Division of …
Form O-71(Rev. 12-19) State of New JerseyDivision of TaxationTransfer Inheritance and Estate TaxPO Box 249 Trenton, NJ 08695-0249To the Director, Division of Taxation:Pursuant to 18 and 18 , notice is hereby given of the following sum or sums paid or payable by the undersigned organization as a result of the death of the following New Jersey resident:Name of DecedentSocial Security NumberDate of DeathResidence at Death (Street Address, City, State , ZIP Code)CountyDate of Birth (Optional)Policy or Contract NumberDate of IssueOwner of PolicyDate of Assignment (If ownership acquired from decedent)Kind and Description of Policy or Contract (Do Not Abbreviate or Use Symbols)Annuity Life Insurance Endowment Other Beneficiary Provide separate form for each beneficiaryFace Amount of Policy (entire policy).
Additional information pertaining to the use of Form 0-71 can be obtained by contacting the Inheritance and Estate Tax Branch of the Division of Taxation by mail at the Division of Taxation, Inheritance and Estate Tax Branch, PO. Box 249, Trenton, New Jersey 08695-0249 or by phone at 609-292-5033.
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