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(12/08)

PMF 400

ISBA P706

IN THE IOWA DISTRICT COURT FOR _______________ COUNTY

IN THE MATTER )

) Probate No.

OF THE ESTATE OF )

) REPORT AND INVENTORY

____________________________, )

Deceased. )

The undersigned Executor, , whose post office address is , reports as follows:

|Name of |Age |Last Known |Date of |

|Decedent | |Address |Death |

| | | | |

1. The designated attorney is , whose address and telephone number is 115 First Avenue S.E., P.O. Box 1968, Cedar Rapids, Iowa 52406-1968, (319) 362-2137.

2. Amount of gross estate for Federal Estate Tax purposes: $ _____________

Will a Federal Estate Tax Return be filed? Yes No

3. The decedent died testate.

4. If testate, was a child born to or adopted by decedent after execution of the Will? Yes No

5. Did decedent leave a surviving spouse? Yes No

6. List (a) surviving spouse, if any; (b) beneficiaries under decedent's Will; (c) heirs at law; (d) transferees; and (e) surviving joint tenants.

|Name |Age |Post Office Address |Relationship |

| | | |to Decedent |

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(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE A--REAL ESTATE

(Jointly owned property must be disclosed on Schedule E)

|Item |Description |Alternate |Alternate |Value at |

|Number | |Valuation Date |Value |Date of |

| | | | |Death |

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| |TOTAL. Enter in Recapitulation | | |$________ |

SCHEDULE A

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE B--STOCKS AND BONDS

(Jointly owned property must be disclosed on Schedule E)

|Item |Description Including Face Amount of Bonds or Number of Shares |Unit |Alternate |Value at |

|Number |and Par Value Where Needed for Identification |Value |Value |Date of Death |

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| |TOTAL. Enter in Recapitulation | | |$_____ |

SCHEDULE B

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE C--MORTGAGES, NOTES AND CASH

(Jointly owned property must be disclosed on Schedule E)

|Item |Description |Alternate |Alternate |Value at |

|Number | |Valuation Date|Value |Date of |

| | | | |Death |

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| |TOTAL. Enter in Recapitulation | | |$____ |

SCHEDULE C

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE D--INSURANCE ON THE DECEDENT'S LIFE

Identify policy or contract, designated beneficiary, amount, and show value. Also identify each item as to whether it is includible or excludible in the estate subject to Iowa inheritance tax.

|Item |Description |Alternate |Alternate |Value at |

|Number | |Valuation Date |Value |Date of Death |

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| |TOTAL | | |$__________ |

| |Less amounts excluded for Iowa Inheritance Tax | | |$__________ |

| |Amount subject to Iowa Inheritance tax. Enter in Recapitulation | | |$_________ |

SCHEDULE D

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE E - JOINTLY OWNED PROPERTY WITH SURVIVING SPOUSE ONLY

|Item Number |Description |Alternate Valuation|Alternate |Value at Date of|

| | |Date |Value |Death |

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|TOTAL of Schedule E | |$______ |

|AMOUNT INCLUDED (One-half). Enter on the recapitulation | |$______ |

SCHEDULE E

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE E-1 - ALL OTHER JOINT INTERESTS

(INCLUDING PROPERTY HELD

WITH SURVIVING SPOUSE AND ONE OR MORE THIRD PARTIES)

State the name and address of each surviving co-tenant. If there are more than 5 surviving co-tenants,

list the additional co-tenants on an attached sheet.

| | |

|Name |Address (Number and Street, City, State, and ZIP Code) |

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|Item No. |Enter Letter |Description |Percentage |Includible |Includible Value|

| |for Co-Tenant |(Include Alternate Valuation Date, If Any) |Includible |Alternate |at Date of Death|

| | | | |Valuation | |

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|TOTAL of Schedule E-1. Enter on the Recapitulation | |$______ |

SCHEDULE E-1

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE F--MISCELLANEOUS PROPERTY NOT REPORTABLE

UNDER ANY OTHER SCHEDULE

(Jointly owned property must be disclosed on Schedule E)

|1. Did the decedent, at the time of death, own any articles of artistic or collectible value in excess of $3,000 or any |Yes |No |

|collections whose artistic or collectible value combined at date of death exceeded $3,000? | | |

|If "Yes," full details must be submitted on this schedule | | |

| | | |

|2. Has the decedent's estate, spouse, or any other person, received (or will receive) any bonus or award as a result of | | |

|the decedent's employment or death? | | |

|If "Yes," full details must be submitted on this schedule | | |

| | | |

|3. Did the decedent at the time of death have, or have access to, a safe deposit box? | | |

|If "Yes," state locations, and if held in joint names of decedent and another, state name and relationship of joint | | |

|depositor. | | |

|_______________________________ | | |

| | | |

|If any of the contents of the safe deposit box are omitted form the schedules in this return, explain fully why omitted.| | |

| | | |

|4. Did the decedent, at the time of death, own any other miscellaneous property not reportable under any other schedule?| | |

|If "Yes," full details must be submitted on this schedule. | | |

| | | |

|Item |Description |Alternate |Alternate |Value at |

|Number | |Valuation Date |Value |Date of |

| | | | |Death |

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| |TOTAL. Enter in Recapitulation | | |$_____ |

SCHEDULE F-1--MISCELLANEOUS PROPERTY EXEMPT FROM EXECUTION

|Item |Description |Alternate |Alternate |Value at |

|Number | |Valuation Date |Value |Date of |

| | | | |Death |

| | | | | |

| |TOTAL. Enter in Recapitulation | | | |

SCHEDULE F

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE G - TRANSFERS DURING DECEDENT'S LIFE

THIS FORM NOT FOR USE WITH FEDERAL FORM 706.

|Item Number |Description |Alternate |Alternate Value |Value at Date of Death |

| | |Valuation Date | | |

| |A. List all gifts made within three years of death in | | | |

| |excess of the gift tax exclusions allowable under I.R.C. | | | |

| |Section 2503(b) and (e). Indicate the name and relationship| | | |

| |of the donee, and date gifts were made. | | | |

|1. | | | | |

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| | | | | |

| |None. | | | |

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| |B. List all transfers in which the decedent retained a life| | | |

| |estate or interest, or which were to take effect in | | | |

| |possession or enjoyment at death. List the date of the | | | |

| |transfers, the description of the property transferred, the| | | |

| |consideration, if any, the value of the property at death, | | | |

| |or the alternate value if elected, and the name and | | | |

| |relationship of the transferee. | | | |

|1. | | | | |

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| |None. | | | |

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|TOTAL. Enter on the Recapitulation | |$______ |

SCHEDULE H - POWERS OF APPOINTMENT

|Item Number |Description |Alternate |Alternate Value |Value at Date of Death |

| | |Valuation Date | | |

|1. | | | | |

| | | | | |

| |None | | | |

| | | | | |

| | | | | |

|TOTAL. Enter on the Recapitulation | |$0.00 |

SCHEDULE G & H

(12/08)

PMF 400

ISBA P706

_______________________________________________________________________________

Estate of

_______________________________________________________________________________

SCHEDULE I - ANNUITIES

List the full amount of each annuity payable as a result of the decedent's death. As part of the description of the annuity, identify the amount payable and the beneficiary of the annuity. If any annuity is payable from a qualified plan or IRA in two or more installments, identify, as part of the description, the amount of each qualified plan or IRA excluded for Iowa inheritance tax purposes. Deduct the total of all exclusions where indicated.

|Item Number |Description |Alternate Valuation |Alternate Value |Value at Date of |

| | |Date | |Death |

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|TOTAL | |$________ |

|Less amounts excluded for Iowa inheritance tax | |0.00 |

|Amount subject to Iowa inheritance tax. Enter on the Recapitulation | |$________ |

SCHEDULE I

(12/08)

PMF 400

ISBA P706

QUESTIONNAIRE AND RECAPITULATION

Answer all questions

ATTACH ONLY SCHEDULES APPLICABLE. If Schedule is not attached, state NONE.

|A. Did the decedent at time of death own any real | | |H. Did the decedent possess a general power of | |

|estate not held in joint tenancy? If yes, complete | | |appointment over any property, or did the decedent | |

|Schedule A. | | |exercise or release a general power of appointment, | |

| | | |within three years of death? If yes, complete | |

| | | |Schedule H. | |

|B. Did decedent at time of death own any stocks or | | |I. Did the decedent own or have an interest in any | |

|bonds not held in joint tenancy? If yes, complete | | |annuities, supplementary or other income contracts, | |

|Schedule B. | | |retirement benefits or pension funds? If yes, | |

| | | |complete Schedule I. | |

|C. Did decedent at time of death own any mortgages, | | | | |

|notes or cash not held in joint tenancy? If yes, | | |TOTAL OF SCHEDULES (Iowa gross estate) | |

|complete Schedule C. | | | | |

|D. Is there any insurance on the life of decedent? | | |Less exclusions, if any (Before exemptions | |

|If yes, complete Schedule D. | | |and deductions) | |

|E. Did decedent at time of death own any property | | |SUBTOTAL | |

|held in joint tenancy with spouse? If yes, | | | | |

|complete Schedule E. | | | | |

| | | |Less Mortgages and estimated debts | |

|E-1. Did decedent at the time of death own any | | |TOTAL | |

|property held in joint tenancy with others? If | | | | |

|yes, complete Schedule E-1. | | | | |

|F. Did decedent at time of death own any other | | |INFORMATION RESPONSIVE TO SECTIONS | |

|property not shown on any other schedule? If yes,| | |633.361.9, .12 AND .13, THE CODE. | |

|complete Schedule F. | | | | |

|F-1. If intestate or election to take against the | | |1. Did the decedent die owning real estate located | |

|Will, did decedent at the time of death own any | | |outside the State of Iowa not otherwise reported? If| |

|property exempt from execution? If yes, complete | | |yes, attach Schedule showing extent of interest, | |

|Schedule F-1. | | |legal description, and estimated value. | |

|G. Did the decedent make any gift within three years| | |2. Is any other property required to be reported for | |

|of death in excess of the gift tax exclusions | | |federal estate tax or Iowa inheritance tax purposes | |

|allowable under I.R.C. Section 2503(b) and (e)? Did | | |which has not been reported on Schedules A through I?| |

|the decedent, prior to death, make any transfer | | |If yes, attach Schedule showing items and values. | |

|where the decedent retained a life estate or | | | | |

|interest, or which were to take effect in possession| | | | |

|or enjoyment at death? If yes, complete | | | | |

|Schedule G. | | | | |

| | | |3. Was any gift made by decedent that reduced the | |

| | | |amount of the unified credit available for federal | |

| | | |estate tax purposes? If yes, attach Schedule showing | |

| | | |the description and value of the gift, date and | |

| | | |amount of unified credit claimed. | |

CERTIFICATION

I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.

Date Capacity or Title Signature

________________ Executor _______________________________________

Estate of _________________________, deceased.

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