United States Estate (and GenerationSkipping Transfer) Tax Return

Form 706-NA

OMB No. 1545-0531 (Rev. January 2003) Estate of nonresident not a citizen of the United States

Department of the Treasury

Internal Revenue Service (See separate instructions. Section references are to the Internal Revenue Code.)

Attach supplemental documents and translations. Show amounts in U.S. dollars.

Decedent, Executor, and Attorney

1a Decedent’s first (given) name and middle initial b Decedent’s last (family) name 2 U.S. social security number (if any)

3 Place of death 4 Domicile at time of death 5 Citizenship (nationality) 6 Date of death

7a Date of birth b Place of birth 8 Business or occupation

9a Name of executor 10a Name of attorney for estate

In

United

States

b Address b Address

11a Name of executor 12a Name of attorney for estate

Outside

United

States

b Address b Address

Tax Computation

1 Taxable estate (from Schedule B, line 8) 1

2 Total taxable gifts of tangible or intangible property located in the U.S., transferred (directly or indirectly)

by the decedent after December 31, 1976, and not included in the gross estate (see section 2511) 2

3 Total (add lines 1 and 2) 3

4 Tentative tax on the amount on line 3 (see page 4 of instructions) 4

5 Tentative tax on the amount on line 2 (see page 4 of instructions) 5

6 Gross estate tax (subtract line 5 from line 4) 6

7 Unified credit—enter smaller of line 6 amount or maximum allowed (see page 4 of instructions) 7

8 Balance (subtract line 7 from line 6) 8

9 Credit for state death taxes (see page 4 of instructions and attach credit evidence) 9

10 Balance (subtract line 9 from line 8) 10

11

Credit for tax on prior transfers (attach Schedule Q, Form 706)

11

12

Other credits (see page 4 of instructions)

12

13 Total (add lines 11 and 12) 13

14 Net estate tax (subtract line 13 from line 10) 14

15 Total generation-skipping transfer tax (attach Schedule R, Form 706) 15

16 Total transfer taxes (add lines 14 and 15) 16

17 Earlier payments (see page 4 of instructions and attach explanation) 17

18 U.S. Treasury bonds redeemed to pay estate tax 18

19 Total (add lines 17 and 18) 19

20 Balance due (subtract line 19 from line 16) (see page 4 of instructions) 20

Under penalties of perjury, I declare that I have examined this return, including any additional sheets attached, and to the best of my knowledge and belief, it is true,

correct, and complete. I understand that a complete return requires listing all property constituting the part of the decedent’s gross estate (as defined by the statute)

situated in the United States.

(Signature of executor) (Date)

(Signature of preparer (other than executor)) (Address) (Date)

For Paperwork Reduction Act Notice, see the separate instructions. Form 706-NA (Rev. 1-2003)

Part I

Part II

Cat. No. 10145K

(To be filed for decedents dying after December 31, 2001.)
Form 706-NA (Rev. 1-2003) Page 2

General Information

Yes No Did the decedent make any transfer (of Yes No

property that was located in the United States

at either the time of the transfer or the time

of death) described in sections 2035, 2036,

2037, or 2038 (see the instructions for Form

706, Schedule G)?

7

1a Did the decedent die testate?

Were letters testamentary or of administration

granted for the estate?

b

If granted to persons other than those filing the

return, include names and addresses on page 1. If “Yes,” attach Schedule G, Form 706.

2 Did the decedent, at the time of death, own any: At the date of death, were there any trusts in

existence that were created by the decedent

and that included property located in the

United States either when the trust was

created or when the decedent died?

8

a Real property located in the United States?

b U.S. corporate stock?

Debt obligations of (1) a U.S. person, or (2) the

United States, a state or any political

subdivision, or the District of Columbia?

c

If “Yes,” attach Schedule G, Form 706.

d Other property located in the United States? 9 At the date of death, did the decedent:

Was the decedent engaged in business in the

United States at the date of death?

3 Have a general power of appointment over

any property located in the United States?

a

At the date of death, did the decedent have b Or, at any time, exercise or release the power?

access, personally or through an agent, to a

safe deposit box located in the United States?

4

If “Yes” to either a or b, attach Schedule H, Form 706.

10a Have Federal gift tax returns ever been filed?

At the date of death, did the decedent own

any property located in the United States as

a joint tenant with right of survivorship; as a

tenant by the entirety; or, with surviving

spouse, as community property?

5

b Periods covered 

c IRS offices where filed 

11 Does the gross estate in the United States

include any interests in property transferred

to a “skip person” as defined in the

instructions to Schedule R of Form 706?

If “Yes,” attach Schedule E, Form 706.

Had the decedent ever been a citizen or resident

of the United States (see page 2 of instructions)?

6a

If “Yes,” did the decedent lose U.S. citizenship

or residency within 10 years of death?

If “Yes,” attach Schedules R and/or R-1, Form

706.

b

Schedule A—Gross Estate in the United States (see page 2 of instructions) Yes No

Do you elect to value the decedent’s gross estate at a date or dates after the decedent’s death (as authorized by section 2032)?

To make the election, you must check this box ‘‘Yes.’’ If you check ‘‘Yes,’’ complete all columns. If you check ‘‘No,’’ complete columns

(a), (b), and (e). You may leave columns (c) and (d) blank or you may use them to expand your column (b) description.

(a)

Item

no.

(e)

Value at date of

death in U.S. dollars

(d)

Alternate value in

U.S. dollars

(c)

Alternate

valuation date

(b)

Description of property and securities

For securities, give CUSIP number.

1

(If you need more space, attach additional sheets of same size. )

Total 

Schedule B—Taxable Estate

You must document lines 2 and 4 for the deduction on line 5 to be allowed.

1 Gross estate in the United States (Schedule A total) 1

2 Gross estate outside the United States (see page 3 of instructions) 2

3 Entire gross estate wherever located (add amounts on lines 1 and 2) 3

Amount of funeral expenses, administration expenses, decedent’s debts, mortgages and liens, and

losses during administration (attach itemized schedule) (see page 3 of instructions)

4

4

5 Deduction for expenses, claims, etc. (divide line 1 by line 3 and multiply the result by line 4) 5

Charitable deduction (attach Schedule O, Form 706) and marital deduction (attach Schedule M, Form

706, and computation)

6

6

7 Total deductions (add lines 5 and 6) 7

8 Taxable estate (subtract line 7 from line 1) (enter here and on line 1 of the Tax Computation) 8

Part III

Form 706-NA (Rev. 1-2003)