ET 21
                                                                                                                              Rev. 4/12
                Estate Tax Unit                                 Reset Form                                    Date Received by
                P.O. Box 183050                                                                         Ohio Department of Taxation
                Columbus, OH 43218-3050
                1-(800) 977-7711
                tax.ohio.gov

            Application for Certifi cate of Release of Ohio Estate Tax Lien
                                    For dates of death July 1, 1983 – Dec. 31, 2012

Estate of: Decedent’s last name                     Decedent’s fi rst name and initial                   Date of death

County in Ohio                      Case number                    Decedent’s Social Security #               Has an Ohio estate tax
                                                                                                                   return been fi led?
                                                                                                                     Yes       No
                                                                                                              If “yes,” give date it was fi led
Name of preparer
                                                                                                                   Month/Day/Year
Address
                                                                                                        Amount of tax paid or to be paid
City, state and ZIP code
                                                                                                        $
Telephone number of preparer

Please check the appropriate title (including ancillary executor or administrator):     Attorney Executor  Administrator(s) 

       List the approximate value of the real estate on the appropriate schedule below, list all
            other gross assets under “All Other Property,” then list deductions as shown.

                   Approximate Gross Estate Values                                Name and address of the purchaser, transferee or 
Schedule A                                                                        mortgagee and state relation to applicant decedent.
Real estate                                     $ 

Schedule E
                                                $
Jointly owned property 

Schedule G                                      $
Transfers during decedent’s life 

Schedule H                                      $
Power of appointment property                                                     Purchase/sales price on property:

All other property                              $                                 $ 
Total gross estate                              $                                 Will the estate be claiming any of the following on the 
                                                                                  estate tax return (estate tax form 2):
J  Debts and expenses of administration         $
K Charitable deductions                         $                                  Yes  No
                                                                                                Current agricultural use valuation
L Marital deduction                             $                                                 (CAUV) per Ohio Revised Code 
                                                                                                  R.C.) section 5731.011
T Qualifi ed family-owned business               $                                  Yes  No
interest deduction                                                                              Extension of time to pay estate tax 
                                                                                                  per R.C. section 5731.25
Total deductions (schedules J, K, L and T)      $

                                    To be completed by the Ohio Department of Taxation
The application for this release of Ohio estate tax lien is:      Approved      Not  approved
                    Tax commissioner                                              By                               Date

                                                                                                                        ET 21
                                                                                                                        Rev. 4/12
                                                                                                                        Page 2
Submit this form in duplicate to: Ohio Department of Taxation
                                      Estate Tax Unit
                                      P.O. Box 183050
                                      Columbus, OH  43218-3050 or
                                      Fax (614) 387-1984 

Documents to be attached:

1.  Copy of will and letters of administration or testamentary, if     4.  Attach a statement of the reasons why you are applying for a 
 any.                                                                  release.

2.  Copy of contract of sale, if any.                                  5.  Attach a copy of the latest real estate tax bill received or the 
                                                                       auditor’s tax card.
3.  List below a description of the property to which this application 
 applies, showing the value of the property and the basis of the 
 valuation. Continue on supplemental sheets, if necessary. Include 
 parcel number and address of property to be released.

This certifi cate releases the lien of the state of Ohio imposed by R.C. section 5731.37 on the property described below: