Form Ih-12 - Indiana Inheritance Tax Return For A Non-Resident Decedent Page 2

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StAte oF InDIAnA
)
) SS:
CoUntY oF _______________
)
Before me, a notary Public in and for _________________ County, State of _______________, personally appeared
______________________, who acknowledged execution of the foregoing
document and who, being duly sworn, stated the representations contained herein to be true.
WItneSS my hand and notarial Seal this _______ day of ________________, ___________.
(Signature) _________________________________
(Printed) ___________________________________
notary Public
SeAL
My commission expires: ___________________


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