Form M-4422 - Application For Certificate Releasing Massachusetts Estate Tax Lien
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1
2Rev. 3/04
Form M-4422
Massachusetts
Application for Certificate
Department of
Releasing Massachusetts Estate Tax Lien
Revenue
Only for an estate with a date of death on or after January 1, 2003 and a Massachusetts estate tax is due.
Name of decedent
Date of death
❿
❿
Residence (domicile) at time of death
Social Security number
❿
Probate court
Docket number
Property Being Sold, Transferred or Mortgaged
Name of purchaser, transferee or mortgagee
Relationship to applicant and decedent
Address of purchaser, transferee or mortgagee
Consideration paid or to be paid
Description and location of property to which this application applies, showing the value of the property and the basis of the valuation
Description and gross value of remaining real property in Massachusetts
Power of Attorney.
Authorization to receive confidential information under MGL, Ch. 62C, s.21 and Power of Attorney.
I (We) hereby appoint the undersigned nominee, subject to written revocation, as attorney(s)-in-fact to represent the taxpayer before any office of the
Massachusetts Department of Revenue, to receive confidential information and to perform on my (our) behalf the following acts for this estate:
Strike any of the following that are not granted:
To receive, but not to endorse and collect, checks in payment of any refund of Massachusetts taxes, penalties or interest.
To execute waivers, closing agreements and consents extending the statutory period for assessment or collection of taxes.
To delegate authority or to substitute another representative.
Other acts (specify):
Send copies of notices and other written communications addressed to the taxpayer(s) in proceedings involving the above estate to:
Name
Telephone
Address (Include Zip)
Signature of nominee
Date
Signature of executor, administrator, etc.
Date
Declaration.
The personal representative of the estate is personally liable for transfers of estate assets before all taxes are paid. The
privacy act notice is available upon request. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and
enclosures are true, correct and complete. For Privacy Act Notice see Form M-706 instructions.
Signature(s) of executor(s), administrator(s) or person(s) in possession of property PTIN or SSN
Date
Signature and address of preparer other than the executor(s), etc.
PTIN or SSN
Date
Note.
The Massachusetts estate tax is computed using the Internal Revenue Code (IRC) in effect on December 31, 2000. Changes to the
IRC enacted after December 31, 2000 do not affect the computation of the Massachusetts estate tax. All references to the U.S. Form 706 are
to the form with a revision date of July 1999. This form and instructions are available from DOR’s website at
Form code: 654
5M 12/01 CRP0102
printed on recycled paper
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