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                                                                                                               ET 13 
            Department of                                                                                      Rev. 4/12 
Ohio I   Taxation 
            Estate Tax Unit 
            1-(800) 977-7711 
            tax.ohio.gov                          Reset Form

  Application for Consent to Transfer the Proceeds of Insurance Contracts, 
         Employer Death Beneﬁ ts and Retirement Plans for Resident and 
                   Nonresident Decedents (Ohio Revised Code 5731.39) 
                                For dates of death July 1, 1983 – Dec. 31, 2012 

Part I – Identiﬁcation 
Name of decedent                                  Date of death                     Decedent’s Social Security number 
                                                  I 
Decedent’s address at time of death (number and street, city, state and ZIP code)  County of residence 
 
  Case number 

Is the decedent’s estate in the process of administration?    The gross value of all property held in the decedent’s name  
Yes  F•••No F                                                 alone or owned jointly by decedent at death or transferred 
                                                              by the decedent prior to death; including, but not limited to: 
Name and address of estate representative:                    real estate; cash; automobiles; household goods; insurance  
                                                              payable to an estate, pension plans and annuities payable 
                                                              after death including IRA and Keogh plans (check accord-
                                                              ing to date of death): 
                                                              Date of death (DOD) Jan. 1, 2002 – Dec. 31, 2012 
                                                              F  More than $338,333  F  Under $338,333 
 
                                                              DOD on or after Jan. 1, 2001 thru Dec. 31, 2001 
Name and address of attorney representing estate:             F  More than $200,000  F  Under $200,000 
                                                              DOD on or after June 30, 1983 thru Dec. 31, 2000 
                                                              F  More than $25,000   F  Under $25,000 

                                                              Note: If the gross estate is less than $338,333,$200,000  
                                                              or $25,000 on the applicable date of death, no estate tax 
                                                              return is required to be ﬁled. 

 I hereby certify that all statements made are correct to the best of my knowledge and belief. (Please provide name, 
 address and telephone number of person ﬁ ling this application.) 

                             Signature and title of applicant                                   Date submitted 
            (executor, administrator, survivor or attorney for same – circle one) 

 Applicant’s name            Address                          City, state, ZIP code     Telephone number 

Part II – To Be Completed By Agent of the Tax Commissioner (County Auditor) in the County 
       of the Decedent’s Residence 

 The application for consent to transfer is: Approved F Not approved              F 

 Tax commissioner agent                                       By                                Date

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ET 13
Rev. 4/12
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Part III – Beneﬁ ts Payable by an Insurance Company (to be completed by insurer)

1. A consent is not necessary for straight life insurance payable to a named beneﬁ ciary other than the estate.
2. Please complete Part V – listing all beneﬁ ciaries’ information
3. A separate application consent form is not required for each beneﬁ ciary. Please complete only one consent applica-
tion form for each policy or contract.
Name of insured Owner of policy or contract

Name and address of insurance company Type of policy or contract Number of policy or contract

Value at date of death If annuity, yearly payment

Part IV – Employment-Related Beneﬁ ts (to be completed by employer)

1. A separate application consent form is not required for each beneﬁ ciary. Please complete only one consent applica-
tion form for each death beneﬁt.
2. Please complete Part V – listing all beneﬁ ciaries’ information

Name and address of employer This form is not for IRAs and Keogh plans
held in a banking institution.
Use estate tax forms 12 and 14.

Date of death value $ Check one:• F•IRA F•Keogh F•Other

Lump sum $ Annually $ Monthly $ Other

Part V – Beneﬁ ciary Information
Please complete the beneﬁ ciary information as it applies to Part III and Part IV above.

Beneﬁ ciary’s Name Address Relationship to Decedent

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ET 13
Rev. 4/12
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General Information

All county auditors have been appointed agents of the tax commissioner for the purpose of issuing con-
sents to transfer (R.C. section 5731.41)

How to obtain Submit this completed application to the county auditor in the county of the
a release decedent’s residence. The county auditor will review the application and return a
copy to the applicant. If the name and address of the county auditor are needed,
please call the Ohio Department of Taxation, Estate Tax Unit, at 1-800-977-7711.

1. Complete a separate application for each beneﬁt.
2. Application will not be processed unless completed in its entirety and signed by the
applicant.
3. The approval of a consent to transfer does not determine a tax liability.
4. The county auditor will forward a copy of the approved application to the tax com-
missioner.

For nonresident decedents, submit this completed application to the Ohio Depart-
ment of Taxation, Estate Tax Unit, P.O. Box 183050, Columbus, OH 43218-3050. This
unit will review the application and return a copy to the applicant.

A consent must be obtained for the following:
When a consent to
transfer is required 1. Annuities payable to a named beneﬁ ciary or the estate.
2. Matured endowments payable to a named beneﬁ ciary or the estate.
(R.C. section 5731.09(A)
3. Supplemental contracts payable to a named beneﬁ ciary or the estate.
and (B) and R.C. section 4. Straight life insurance payable to the estate.
5731.39 (C) and (D) 5. Life insurance owned by decedent on the life of another person.
6. Employer-related death beneﬁ ts in excess of $2,000, including:
a. retirement beneﬁ ts payable to a named beneﬁciary or the estate;
b. pension or proﬁt-sharing plans payable to a named beneﬁciary or the estate;
c. IRAs payable to a named beneﬁciary or the estate;
d. Keoghs payable to a named beneﬁciary or the estate;
e. corporate plans, whether qualiﬁed or unqualiﬁed, payable to a named beneﬁciary
or the estate;
f. any deferred compensation program; and
g. bonus plans.

A consent is not required for the following:
When a consent
to transfer is not 1. Date of death is after Dec. 31, 2012. H.B. 508, 129th General Assembly, revised R.C.
section 5731.39. A tax release or consent to transfer is not required for individuals
required
with a date of death after Dec. 31, 2012.
(R.C. section 5731.09) 2. Straight life insurance beneﬁts payable to a named beneﬁciary other than the estate;
or
3. When any of the above-listed assets are payable to the surviving spouse and the
date of death is on or after 10/01/96; or
4. Any of the above-listed assets are $25,000 or less, regardless of beneﬁ ciary; or
5. The Federal Coal Mine and Safety Act annuity payable under Title IV of 1969 (black
lung beneﬁts).

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