File No.
STATE OF NORTH CAROLINA
                                                County                                                             In The General Court Of Justice 
                                                                                                                   Before The Clerk
              IN THE MATTER OF THE ESTATE OF
Name Of Decedent
                                                                                  ESTATE TAX CERTIFICATION 
                                                                                  (FOR DECEDENTS DYING ON OR AFTER  
                                                                           JANUARY 1, 1999, BUT PRIOR TO JANUARY 1, 2013) 
Date Of Death
                                                                                                                                   G.S. 28A-21-2, 28A-25-3
NOTE: Use this form for a decedent who died on or after 1/1/1999, but prior to 1/1/2013. For a decedent who died before 1/1/1999, 
use AOC-E-207. An estate tax certification under G.S. 28A-21-2(a1) is not required for a decedent who died on or after 1/1/2013.
I, the personal representative/fiduciary/spouse in the above estate, certify that:
  1.   a.   The decedent died on or after 1/1/1999, but prior to 1/1/2010, and the gross value of the estate at the time of the decedent’s 
              death was less than:                                    
                 $650,000 (If decedent died on or after 1/1/1999).          $1,500,000 (If decedent died on or after 1/1/2004).
                 $675,000 (If decedent died on or after 1/1/2000).          $2,000,000 (If decedent died on or after 1/1/2006).
                 $1,000,000 (If decedent died on or after 1/1/2002).        $3,500,000 (If decedent died on or after 1/1/2009).
       b.   The decedent died on or after 1/1/2010, but prior to 1/1/2013, and there is no federal estate tax due or payable. 
  2.  I am the surviving spouse and sole heir of the decedent.
  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 or 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 - there, include one-half.)   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.)                   Value
Description And Location
                                                                                                                                   $

                                                                  TRANSFERS
(Total Value Of Transfers from Side Two)                                                                                           $               0.00

              TOTAL VALUE OF PERSONAL PROPERTY, REAL PROPERTY, AND TRANSFERS                                                       $               0.00

                                                       Original - File     Copy - Taxpayer
                                                                     (Over)
 AOC-E-212, Rev. 12/17
 © 2017 Administrative Office of the Courts

      Use the space below to explain any transfers over which the decedent retained any interest (such as a 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 TRANSFERS                            $                      0.00

Date                         Signature                                       Date                   Signature

Title Of Personal Representative/Fiduciary/Spouse                            Title Of Personal Representative/Fiduciary/Spouse

Address Of Personal Representative/Fiduciary/Spouse                          Address Of Personal Representative/Fiduciary/Spouse

SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME                                   SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date             Signature Of Person Authorized To Administer Oaths          Date                   Signature Of Person Authorized To Administer Oaths

      Deputy CSC               Assistant CSC         Clerk Of Superior Court       Deputy CSC        Assistant CSC               Clerk Of Superior Court
                 Date Commission Expires                                     Date Commission Expires
       Notary                                                                                                                       Notary
                 County Where Notarized                                      County Where Notarized
     SEAL                                                                                                                          SEAL

NOTE TO PERSONAL REPRESENTATIVE/FIDUCIARY/SPOUSE AND CLERK:
The final accounting of an estate of a decedent who died before January 1, 2013 should not be approved unless the personal representative files with the 
Clerk of Superior Court an Estate Tax Certification, (AOC-E-212 or AOC-E-207) or a certificate issued by the Secretary of Revenue stating the estate tax 
liability has been satisfied. 

 AOC-E-212, Side Two, Rev. 12/17
 © 2017 Administrative Office of the Courts