Arizona Form                                 Notice of Assumption of Duties 
               210                                                in a Fiduciary Capacity
                                           Complete and mail to:  Attention: Fiduciary Unit
                                                                  Arizona Department of Revenue
                                                                  Box B-06
                                                                  1600 West Monroe
                                                                  Phoenix, AZ  85007-2650
                             For Assistance:
                             • Call: (602) 716-7809 or 
                             • Email: Fiduciary@azdor.gov.
Notice is hereby given of the assumption of duties in a fiduciary capacity in the estate named below pursuant to 
A.R.S. § 43-1366.
Section 1         Decedent Information
Full Name of Decedent                                            Decedent’s Social Security Number Decedent’s Date of Death
                                                                                                  M M D D Y Y Y Y
                                                                 Estate’s Employer I.D. Number    Decedent’s Date of Birth
                                                                                                  M M D D Y Y Y Y
Full Name of Spouse                                              Spouse’s Social Security Number  If spouse is deceased, Date of Death
                                                                                                  M M D D Y Y Y Y
Last known home address of decedent – number and street          City, Town or Post Office                    State  ZIP Code

Date domicile was established in Arizona (If nonresident, describe Arizona property on a separate schedule):  M M D D Y Y Y Y  
Mailing Address – if different from home address                 City, Town or Post Office                    State  ZIP Code

Section 2         Fiduciary Information
Name of Fiduciary                                                                              Telephone Number (with area code)

Address – number and street                                      City, Town or Post Office                    State  ZIP Code

Section 3         Probate Information
County in which estate is being probated         Probate Number                                  Date of Fiduciary’s Appointment 
                                                                                                 M M D D Y Y Y Y
Name of Attorney                                                                                 Telephone Number (with area code)

Address – number and street                                      City, Town or Post Office                    State  ZIP Code

Section 4         Estate Information
Approximate Value of Entire Gross Estate         Approximate Value of Probate Estate
$                                                $
Name of Beneficiary (Include additional sheet if necessary to list additional beneficiaries.)    Beneficiary’s EIN or SSN
                                                                                                  
Address of Beneficiary – number and street                       City, Town or Post Office                    State  ZIP Code

Section 5         Termination of Fiduciary Relationship
                      Complete this section only if you are terminating a prior notice of a fiduciary relationship.

If you are terminating a prior notice concerning fiduciary relationships on file with the Arizona Department of Revenue, check this box ........... 
Enter the date the fiduciary capacity was terminated:  M M D D Y Y Y Y

Signature

►                                                                                                                    
 SIGNATURE OF FIDUCIARY                                    TITLE                                                    DATE
NOTE:  Tax information on file with the department is confidential.  If the fiduciary wants the department to discuss tax matters with someone other than 
the fiduciary, the fiduciary must authorize the department to release confidential information to that person.  If a fiduciary wishes to authorize an individual 
to represent or perform certain acts on behalf of the entity, a Power of Attorney must be filed and signed by the fiduciary acting in the position of the 
taxpayer.  Use Arizona Form 285 for this purpose.  Form 285 may be filed with Form 210.  You may obtain Form 285 from our website at www.azdor.gov
ADOR 10124 (22)
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