HomeMy WebLinkAbout2667
. , b 1 1 s ~U[
REAI. PItOi'EliTY ~ ~farket Value CSC
L're
1:~~.~1 eatate owncjd by deceased and spou~e by entireties ______ $
~).r~er real estate in this State owned by de:,eased ____________ $_ ~
-:eul estate owned outside ~'orth Carolina;
?`'ature oi intere~t _ Total Value _ _ _ _ _ _ S ~
Total Value of All Real Estate ________________ _$ H~~'~
TOTAL APPROXIDiATE VALUE OF ALL PROPERTIES: ___________ _____ S
WRONGFUL DEATH ACTION
~~~•orn Lo and subscriUed before me this
~__ day of October __~ lg 80,
~
~ ' _.~ • ~
i1~ Officer suthorized to administer oaths
hssistant Clerk Superior Cou~t
Signature of Applicant
Jiailing Address
s
Three copiea mailed to the Department of Rerenue, Inheritance Taz Di~ision, Ralei~h. North Carolina. as required by G.S. 105-22.
',ttacner3 is a list of contents of safe deposit box in ___ -__-_ _____ __ _
Bank
Address of Bank
~' •
::,;: _ _~_ de of _ . C, e , .t/:L~~
Y -~ - ___, 19S~f~ L~~~ t' _ r ______ __
U Assistant Cler;c o: Scperior Court
:'~: CSC use-$ond) Do not use this gpacc
': '~ i'"r.: A~fOi3\T: -
~..;. 105-22, G.S. 2isa-4-1, 28a-6-1
.'; ~GL Form 1
i:rv. 2/79
n~~K 351 pa~E2F~3
xt. ~, Box ~39~3, Fairview, N.C. 2873t3
Mailing Address