ET 21 
               Depa!1ment of                                                                                            Rev. 4/12 
Ohio I         Taxation 
               Estate Tax Unit                               Reset Form                                   Date Received by 
               P.O. Box 183050                                                                       Ohio Department of Taxation 
               Columbus, OH 43218-3050 
               1-(800) 977-7711 
               tax.ohio.gov 

               Application for Certifi cate of Release of Ohio Estate Tax Lien 
                                 For dates of death July 1, 1983 – Dec. 31, 2012 

Estate of: Decedent’s last name               Decedent’s fi rst name and initial                      Date of death 

County in Ohio                   Case number                  Decedent’s Social Security #                Has an Ohio estate tax 
                                                                                                             return been filed? 
                                                                                                              Yes      No 
                                                                                                          If “yes,” give date it was filed 
Name of preparer 
                                                                                                             Month/Day/Year 
Address 
                                                                                                     Amount of tax paid or to be paid 
City, state and ZIP code 
                                                                                                     $ 
Telephone number of preparer 

Please check the appropriate title (including ancillary executor or administrator):  Attorney Executor Administrator(s) 

        List the approximate value of the real estate on the appropriate schedule below, list all 
               other gross assets under “All Other Property,” then list deductions as shown. 

                   Approximate Gross Estate Values                         Name and address of the purchaser, transferee or 
Schedule A                                                                 mortgagee and state relation to applicant decedent. 
Real estate                                 $ 

Schedule E 
                                            $ 
Jointly owned property 

Schedule G                                  $ 
Transfers during decedent’s life 

Schedule H                                  $ 
Power of appointment property                                              Purchase/sales price on property: 
All other property                          $                              $ 
Total gross estate                          $                              Will the estate be claiming any of the following on the 
                                                                           estate tax return (estate tax form 2):
J  Debts and expenses of administration     $ 
K Charitable deductions                     $                               Yes       No 
                                                                                             Current agricultural use valuation 
L Marital deduction                         $                                                  (CAUV) per Ohio Revised Code 
                                                                                               R.C.) section 5731.011 
T Qualifi ed family-owned business                                           Yes       No 
 interest deduction                         $                                                Extension of time to pay estate tax 
                                                                                               per R.C. section 5731.25 
Total deductions (schedules J, K, L and T)  $ 

                                 To be completed by the Ohio Department of Taxation 
The application for this release of Ohio estate tax lien is:   Approved   Not approved 
                   Tax commissioner                                        By                                Date 

                                                                                                                         ET 21 
                                                                                                                         Rev. 4/12 
                                                                                                                         Page 2 
Submit this form in duplicate to:    Ohio Department of Taxation 
                                     Estate Tax Unit 
                                     P.O. Box 183050 
                                     Columbus, OH 43218-3050 or 
                                     Fax (614) 387-1984 

Documents to be attached: 

1. Copy of will and letters of administration or testamentary, if     4. Attach a statement of the reasons why you are applying for a 
   any.                                                                  release. 

2. Copy of contract of sale, if any.                                  5. Attach a copy of the latest real estate tax bill received or the 
                                                                         auditor’s tax card. 
3. List below a description of the property to which this application 
   applies, showing the value of the property and the basis of the 
   valuation. Continue on supplemental sheets, if necessary. Include  
   parcel number and address of property to be released. 

This certifi cate releases the lien of the state of Ohio imposed by R.C. section 5731.37 on the property described below: