State of Rhode Island Division of Taxation 
  Form T-79 
  Application for Estate Tax Waiver                                                                  16160799990101

Decedent's first name                             MI     Last name                                   Suffix

Decedent’s address - legal residence (domicile) at time of death ("late of")                               Date of Death:

Address 2

City, town or post office                                                                                  State ZIP code

1 Has Form RI-706 been filed? .................................................................... 1       Yes           No

2 Number of shares or face amount of bond ................................................         2

3 Name of Company     ...........................................   3

4 Held in the name of   ........................................... 4

         A SEPARATE APPLICATION MUST BE COMPLETED FOR EACH COMPANY 
                                                                      
                          THIS FORM SHOULD BE TYPED

                          FOR OFFICIAL USE ONLY 

                          ACCOUNT ID: 

                          This is to certify that authority is hereby given to transfer the above  
                          described property belonging to the estate of the above named decedent.

                                                                      Tax Administrator

                          VALID ONLY WHEN SEAL AFFIXED

                                                                                                                           Revised 12/2021