File No.
STATE OF NORTH CAROLINA

                                               County                                                       In The General Court Of Justice

           IN THE MATTER OF THE ESTATE OF:
Deceased
                                                                                         INHERITANCE AND ESTATE
Date Of Death (See Reverse)                                                                TAX CERTIFICATION
                                                                                                                            G.S. 28A-21-2; 105-22, -23
I, the personal representative in the above estate, certify that:
1. The gross value of the estate, including any property transferred by the decedent over which the decedent had retained any interest
     as described in G.S. 105-2(a)(3), as well as any property transferred within three (3) years prior to the date of the decedent's death, 
     is less than
     $75,000 (If decedent died on or after 8/1/85 and before 7/1/86).        $450,000 (If decedent died on or after 7/1/93 and before 1/1/97).
     $150,000 (If decedent died on or after 7/1/86 and before 1/1/87).       $600,000 (If decedent died on or after 1/1/97).
     $250,000 (If decedent died on or after 1/1/87 and before 7/1/93).
     (See reverse.)
2.   The beneficiaries are all Class A beneficiaries, as described in G.S. 105-4(a), (child, grandchild, parent, etc.), or the surviving 
     spouse. (This form should not be used if any one of the beneficiaries is other than spouse or Class A.)
3.   The following is a listing of the amount and value of all the decedent's property, including real property located outside North 
     Carolina, at the time of the decedent's death.  (Real estate owned by husband and wife as tenants by the entirety should be included at 
     one-half the fair market value.  Bank, savings and loan accounts, and other securities owned jointly by husband and wife with right of survivorship 
     should be included at one-half fair market value.)
                                                       PERSONAL PROPERTY
(Include full value of joint ownership deposit accounts and securities except between husband and wife - include one-half.)   Market Value
Cash, Securities, Savings
                                                                                                                            $
Other Personal Property

Life Insurance

                                                       REAL PROPERTY
(If real estate was owned by husband and wife as tenants by the entirety, include one-half value and so 
indicate.)                                                                                                  Tax Value         Market Value
Description And Location
                                                                                                        $                   $

                                                                      TRANSFERS
(Total of item 7 on reverse)                                                                                                $
                                                                                                                                              0.00

        TOTAL VALUE OF PERSONAL PROPERTY, REAL PROPERTY AND TRANSFERS                                                       $                 0.00
                                                                       Date                             Signature 
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date                        Signature                                  Title Of Fiduciary

Title Of Person Authorized To Administer Oaths                         Address Of Fiduciary

                 Date Commission Expires       County Where Notarized
SEAL

                                                       Original - File    Copy - Taxpayer
AOC-E-207, Rev. 3/07                                                   (Over)
© 2007 Administrative Office of the Courts

1. This form is designed to be used only for those estates in which the beneficiary is the spouse and/or all of the other 
   beneficiaries are Class A.

2. This form should be used only when the gross estate, including real property, personal property, life insurance and 
   transfers is less than the following:

   If Decedent Died                                                                To Use This Form
   On Or After                            Before                Gross Estate Must Be Less Than
   8/1/85                                 7/1/86 ...................................................         $  75,000
   7/1/86                                 1/1/87 ...................................................         $150,000
   1/1/87                                 7/1/93 ...................................................         $250,000
   7/1/93                                 1/1/97 ...................................................         $450,000
   1/1/97                     .............................................................................. $600,000

3. This form should indicate whether real property is owned jointly by husband and wife as an estate by the entirety 
   and if so, show only one-half value.

4. Joint deposit accounts and other securities held jointly by husband and wife with right of survivorship should be 
   shown at one-half value. All other joint deposits and other securities should be shown at full value.

5. An inheritance tax return is not required when:  (1) all the beneficiaries are either a spouse, child, grandchild or 
   parent and (2) the gross value of the estate, including property transferred within three years of the decedent's death
   without adequate valuable consideration and transfers over which the decedent retained any interest (such as a life 
   estate), was under the amount shown above.  However, under G.S. 28A-21-2(a) a certification to the Clerk of 
   Superior Court is required and this form should be completed.

6. Please list all beneficiaries and relationship to decedent.

                              NAME                                                 RELATIONSHIP (Spouse, Child, Etc.)

7. Use the space below to explain any transfers over which the decedent retained any interest (such as life estate) as 
   well as any transfers of property within three years of death without adequate valuable consideration.  (List name of 
   donee, date of transfer, description of property and value as of date of death.)

                                                                                                                       Value
                                                                                                                      $

   TOTAL VALUE OF PERSONAL PROPERTY, REAL PROPERTY AND TRANSFERS                                                      $
                                                                                                                            0.00
AOC-E-207, Side Two, Rev. 3/07
© 2007 Administrative Office of the Courts