WISCONSIN DEPARTMENT OF REVENUE
Employe Death Benefit Report                                                                                                   PO Box 8906
For deaths after 12-31-91                                                                                                Madison, WI 53708-8906
                                                                                                                         Telephone (608) 266-2772
1.  Name of payor reporting                                          2.  Name of plan

3.  Name of deceased employe or former employe                                                            4.  Date of death

5.  Address of decedent

6.  Type of payment reported (check only one)
                                               Death benefit                         Other (explain below)
 Annuity                     Profit sharing    Wage Continuation
 Pension                     Bonus             Deferred compensation
7.  Amount of payment if paid in one sum                             Date of payment

8.  If payment will be made by installments, state number and amount of installments, age of beneficiary, mortality table and rate of interest used in 
 determining the value of the installments as of date of death.

    Indicate value as of date of death
9. Names and addresses of beneficiaries                              Relationship to decedent                            Share of benefits payable

10. THE BENEFITS REPORTED ABOVE ARE PAYABLE UNDER A FEDERALLY                        QUALIFIED	           NON-QUALIFIED        PLAN
11.   If the decedent contributed to the plan or toward the benefits reported on this form, please provide the following:
 contributions by decedent $                   contributions by employer to decedent's account $          

                                                               CERTIFICATION
As representative of the payor named above, I certify that the information contained in this report is correct to the best of my knowledge and belief.
Signature                                                      Title                                                       Date

IRA or HR 10 Plan — This form does not have to be completed to report payments from an IRA or HR 10 Plan.

Section 72.34, Wisconsin Statutes provides that every person liable for paying benefits to the estate or a beneficiary of a deceased employe or former 
employe in the form of an annuity, bonus, pension or other benefit under a retirement, deferred compensation or profit-sharing plan taxable under this 
chapter, directly or through a trust or fund created by the employer for such purpose, shall give notice of such obligation to the department within 30 
days following the date of payment, or the date of the initial payment if more than one payment is forthcoming, to the estate or any beneficiary of such 
employe or former employe.

HT-209 (R. 6-09)                                                                                                         Wisconsin Department of Revenue