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4 State of Rhode Island Division of Taxation 4
5 Form ESTATE-V 5
6 Estate Tax Fee Payment Voucher Form 16160399990101 6
7 7
8 8
ESTATE TAX FEE FORM
9 9
10 Decedent's first name MI Last name Suffix Decedent's social security number 10
11 XXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXX XXX 999-99-9999 11
12 Decedent's address - Legal residence (domicile) at time of death City, town or post office State ZIP code 12
13 XXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XX 99999 13
14 Foreign country, if applicable Year domicile established Date of birth Date of death 14
15 XXXXXXXXXXXXXXXXXXXXXXXX 01/01/1900 10/01/1920 10/08/2016 15
16 Executor/personal rep/admin's first name MI Last name Suffix Executor's social security number 16
17 XXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXX XXX 999-99-9999 17
18 Executor's address City, town or post office State ZIP code 18
19 XXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XX 99999 19
20 Preparer's first name MI Last name Suffix Preparer telephone number 20
21 XXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXX XXX (401) 999-9999 21
22 Preparer's firm name, if applicable 22
23 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 23
Preparer's address City, town or post office State ZIP code
24 24
25 25
NameXXXXXXXXXXXXXXXXXXXXXXXXXXXXXand location of court where will was probated or estate administeredXXXXXXXXXXXXXXXXXXXXCase number XX 99999
26 26
27 XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX 27
28 28
29 Part 1: Reason for paying $50 fee NOTE: This form is to be used only to pay the $50 fee, not the estate tax. 29
30 Check the box next to the reason for which you are making a payment. Check only one box. 30
31 31
32 Form 706 return filing 32
33 33
34 Form 706 - Pro Forma return filing 34
35 35
36 Form 706 - Amended return filing 36
37 37
38 Change or correction to information on Form T-77, Discharge of Estate Tax Lien (Taxable Estates only) 38
39 39
40 Change or correction to information on Form T-79, Application for Estate Tax Waiver (Taxable Estates only) 40
41 41
42 Other:_______________________________________________________________________________ 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 Part 2: Amount due 50
51 51
52 1 Amount enclosed............................................................................................................ 1 52
50 00
53 Executor/personal representative/administrator signature Date Telephone number 53
54 54
55 10/08/2021 (999) 999-9999 55
56 Preparer signature Date PTIN 56
57 10/16/2021 P99999999 57
58 I declare that I am the Attorney Certified public Enrolled for the executor and prepared this return for the executor. I am not under suspension or 58
59 (Please check one) accountant agent disbarment from practice before the IRS and am qualified in the state shown above. 59
60 60
61 May the Division of Taxation contact your preparer? YES 61
62 Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908 62
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Rev 10/2021