Rev. 3/04
                                                                  Form M-4422                                                                        Massachusetts
                                             Application for Certificate                                                                             Department of
                                                                                                                                                     Revenue
                     Releasing Massachusetts Estate Tax Lien

Only for an estate with a date of death on or after January 1, 2003 and a Massachusetts estate tax is due.
Name of decedent                                                                                                                        Date of death
❿                                                                                                                                       ❿
Residence (domicile) at time of death                                                                                                   Social Security number
                                                                                                                                        ❿
Probate court                                                                                                                           Docket number

Property Being Sold, Transferred or Mortgaged
Name of purchaser, transferee or mortgagee                                                                                              Relationship to applicant and decedent

Address of purchaser, transferee or mortgagee                                                                                           Consideration paid or to be paid

Description and location of property to which this application applies, showing the value of the property and the basis of the valuation

Description and gross value of remaining real property in Massachusetts

Power of Attorney. Authorization to receive confidential information under MGL, Ch. 62C, s.21 and Power of Attorney.
I (We) hereby appoint the undersigned nominee, subject to written revocation, as attorney(s)-in-fact to represent the taxpayer before any office of the
Massachusetts Department of Revenue, to receive confidential information and to perform on my (our) behalf the following acts for this estate:
Strike any of the following that are not granted:
To receive, but not to endorse and collect, checks in payment of any refund of Massachusetts taxes, penalties or interest.
To execute waivers, closing agreements and consents extending the statutory period for assessment or collection of taxes.
To delegate authority or to substitute another representative.
Other acts (specify):
Send copies of notices and other written communications addressed to the taxpayer(s) in proceedings involving the above estate to:
Name                                                                                                                                    Telephone

Address (Include Zip)

Signature of nominee                         Date                      Signature of executor, administrator, etc.                       Date

Declaration. The personal representative of the estate is personally liable for transfers of estate assets before all taxes are paid. The
privacy act notice is available upon request. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and
enclosures are true, correct and complete. For Privacy Act Notice see Form M-706 instructions.
Signature(s) of executor(s), administrator(s) or person(s) in possession of property PTIN or SSN                                        Date

Signature and address of preparer other than the executor(s), etc.     PTIN or SSN                                                      Date

Note. The Massachusetts estate tax is computed using the Internal Revenue Code (IRC) in effect on December 31, 2000. Changes to the
IRC enacted after December 31, 2000 do not affect the computation of the Massachusetts estate tax. All references to the U.S. Form 706 are
to the form with a revision date of July 1999. This form and instructions are available from DOR’s website at www.mass.gov/dor.

Form code: 654                                                         5M 12/01 CRP0102                                                              printed on recycled paper

Part 1. Tentative Massachusetts Estate Tax
1Total gross estate. Enter the amount from the July 1999 revision of U.S. Form 706, page 1, line 1. . . . . . . . . . . . . . . . . ❿                                                          1
2Credit for state death taxes. Enter the amount from the July 1999 revision of U.S. Form 706, page 1, line 15. If this return is for the estate of a Mass-
 achusetts resident decedent who did not own real estate and/or tangible personal property in another state, omit Parts 2 and 3 and enter this amount
 in Part 4, line 1. If this return is for the estate of a Massachusetts resident decedent who owned real estate and/or tangible personal property in
 another state, complete Parts 2 and 4 and omit Part 3. If this return is for the estate of a nonresident decedent with 
 Massachusetts property, omit Part 2 and complete Parts 3 and 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Part 2. Computation of Tax for Estate of Massachusetts Resident Decedent 
with Property in Another State
1Total gross estate, wherever situated. Enter the amount from Part 1, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2Credit for state death taxes. Enter the amount from Part 1, line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3Estate or inheritance taxes actually paid to other states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4Gross value of real estate and tangible personal property in other states. Attach schedule . . . . . . . 4
5Percentage of estate in other states. Divide line 4 by line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5                                %
6Prorated credit. Multiply line 2 by line 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7Deduction allowable for taxes paid to other states. Enter the smaller      of line 3 or line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8Massachusetts estate tax. Subtract line 7 from line 2. Enter result here and in Part 4, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . 8
Part 3. Computation of Tax for Estate of Nonresident Decedent with 
Massachusetts Property
1Total gross estate, wherever situated. Enter the amount from Part 1, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2Credit for state death taxes. Enter the amount from Part 1, line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3Gross value of real estate and tangible personal property in Massachusetts. Enter the total 
 reported on Form M-NRA, line 26. Do not deduct the value of any mortgage or lien . . . . . . . . . . . . 3
4Percentage of estate in Massachusetts. Divide line 3 by line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4                                   %
5Massachusetts nonresident estate tax. Multiply line 2 by line 4. Enter result here and in Part 4, line 1 . . . . . . . . . . . . . . . . . 5
Part 4. Massachusetts Estate Tax Due
1Massachusetts estate tax. Enter the amount from Part 1, line 2, Part 2, line 8 or Part 3, line 5, whichever applies . . . . . . . . 1
2Late file and/or late pay penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4Total amount due. Add lines 1 through 3   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5Payments made with extension. Attach a copy of Form M-4768 and/or Form M-4768A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6Other amounts previously paid. Attach copies of any prior filings with payment dates and amounts . . . . . . . . . . . . . . . . . . . 6
7Total payments. Add lines 5 and 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8Overpayment. If line 4 is smaller than line 7, subtract line 4 from line 7. This is the amount of your potential refund. 
 Refunds are issued only after the filing of a Massachusetts Estate Tax Return, Form M-706. If line 4 is larger than 
 line 7, omit line 8 and complete line 9. If lines 4 and 7 are equal, enter “0” in line 8 and omit line 9 . . . . . . . . . . . . . . . . . . . . 8
9Balance due. If line 4 is larger than line 7, subtract line 7 from line 4. This is the amount of the payment due at time 
 of filing. Make check payable to Commonwealth of Massachusetts             . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿                                  9

Instructions
Note: This form is only for an estate with a date of death on               • check for estimated Massachusetts estate tax due; and
or after January 1, 2003, where a Massachusetts estate tax                  • if the decedent was a nonresident, Form M-NRA, Nonresident
is due.                                                                     Decedent Affidavit.
This form must be completed to obtain a release of estate tax               See the instructions for preparing Form M-706, Massachusetts
lien in cases where the estate is selling or refinancing real estate        Estate Tax Return, for guidance in preparing this form.
that is includible in the decedent’s estate, andthe transaction is
occurring before the due date of the return and a Massachusetts             Note: Form M-4422 is not a substitute for Form M-706, which
estate tax will be due.                                                     must be filed within nine months of the decedent’s death or before
                                                                            any approved extension date.
This form must be accompanied by:
                                                                            Mail to: Massachusetts Department of Revenue, Bureau of Desk
• a copy of the purchase and sale agreement or mortgage                     Audit, Estate Tax Unit, PO Box 7023, Boston, MA 02204.
 commitment;
                                                                            Deliver to: Massachusetts Department of Revenue, Bureau of
• an attested copy of the deed and, if appropriate, any probate             Desk Audit, Estate Tax Unit, 200 Arlington St., Rm. 4300, Chelsea
 document that created the decedent’s interest in the property;             MA 02150.
• Form M-792, Certificate Releasing Massachusetts Estate Tax
 Lien, prepared in triplicate;