Zenith Doc1

Zenith Bank Ghana Limited Nonresident/ Inheritance/ Estate Transfer form PLEASE FILL OUT ALL PAGES OF OUR CONFIDENTIAL FORM Decedent’s first name and middle initial--------------------------------------------------------Last name ----------------------------------------------------------------------------------------Date of death -------------------------------------------------------------------------------------Street address or domicile at time of death------------------------------------------------------Ghana------------------------------------------------------------------------------------------------Name of Next of Kin -------------------------------------------------------------------------------Relationship------------------------------------------------------------------------------------------Marital Status----------------------------------------------------------------------------------------Street address-----------------------------------------------------------------------------------------City/Town---------------------------------------------------------------------------------------------State----------------------------------------------------------------------------------------------------Telephone---------------------------------------------------------------------------------------------E-mail--------------------------------------------------------------------------------------------------Passport #:---------------------------------------------------------------------------------------------Nationality---------------------------------------------------------------------------------------------Date of Birth-------------------------------------------------------------------------------------------Place of Birth------------------------------------------------------------------------------------------Domicile Affidavit This affidavit must be submitted in nonresident cases. The affidavit must be sworn to and signed by the Next of Kin or person having actual or constructive possession of the property, if any. Every question must be answered. Write “not applicable” or “none,” if necessary. Use additional pages if necessary. The undersigned, ________________________________________________________ under penalty of perjury, makes the following statements, based on personal knowledge of the facts set forth herein, for the purpose of establishing the place of decedent’s domicile at the date of death: 1 1 Place where decedent was domiciled at date of death (City, Ghana) ________________________________________________________________________ ________________________________________________________________________ 2 A Place of decedent’s death ________________________________________________________________________ 1

B Home, hospital etc. ________________________________________________________________________ C Place of burial ________________________________________________________________________ D Residence address at death ________________________________________________________________________ E Date and place of birth ________________________________________________________________________ 3 What is your relationship to decedent? ________________________________________________________________________ 4 What are the names and residence addresses of decedent’s surviving spouse and members of the immediate family including children and parents? If none of the above, list brothers and sisters. ________________________________________________________________________ ________________________________________________________________________ (Attach separate listing if necessary.) 5 Did the decedent leave a will? II Yes___ II No___ If yes, name the court(s) which admitted the will to probate, the docket number, the date admitted and also the court(s) which allowed ancillary administration. ________________________________________________________________________ ________________________________________________________________________ (Attach attested copy of the will and petition for probate of will listing the heirs at law unless filed previously.) 6 If the decedent did not leave a will, has next of kin of the estate been appointed? I I Yes___ II No___ If yes, name the court which appointed next of kin and indicate the date of appointment for each. ________________________________________________________________________ ________________________________________________________________________ 7 Did the decedent ever live in Accra? II Yes___ II No___ If yes, during what period(s)? ________________________________________________________________________ ________________________________________________________________________ 8 Indicate the address, nature of decedent’s places of residence (e.g., house rented or owned, apartment, hotel or home of relatives or friends) and lengths of periods outside Accra during the five years preceding death. ________________________________________________________________________ ________________________________________________________________________ 9 To which Ghana or municipality and in what years did the decedent pay a tax on income, real estate, or on intangible property during the last five years? ________________________________________________________________________ ________________________________________________________________________

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10 For which taxable year did the decedent last file a Accra income tax return? ________________________________________________________________________ 11 In what office(s) of the Internal Revenue Service did the decedent file his Federal Income Tax returns during the five years preceding death? What was stated therein to be the decedent’s residence? ________________________________________________________________________ ________________________________________________________________________ 12 What was the decedent’s occupation in the five years preceding death? ________________________________________________________________________ 13 Give name and address of employer. If self-employed, indicate same; if in partnership, give the name and address of the firm and the individual partners. If decedent owned a business, give details. ________________________________________________________________________ ________________________________________________________________________ 14 Did the decedent at any time during the five years preceding death execute a will, codicil, trust indenture, deed, mortgage, lease or any other document in which decedent was described as a resident of Accra? II Yes____ II No___ If yes, describe such document and state what residence address (es) were set forth therein. ________________________________________________________________________ ________________________________________________________________________ 15 Was the decedent a party to any legal proceeding in Accra during the last five years? II Yes____ II No___ If yes, what were the court, date and type of action? ________________________________________________________________________ ________________________________________________________________________ 16 Did decedent belong to any church, lodge, or other social, fraternal or religious club or organization in Accra? II Yes___ II No___ If yes, give name, address, positions held, membership status, etc. ________________________________________________________________________ ________________________________________________________________________ 17 Did the decedent maintain a safe-deposit box or bank accounts in Accra at any time during the five years preceding death? II Yes___ II No___ If yes, give name and address of bank(s). Who, other than the decedent, was authorized to open the box or make withdrawals? ___________________________________________________________________________ ___________________________________________________________________________ 18 Did the decedent hold a Accra driver’s license at any time during the five years preceding death? II Yes____ II No____ If yes, give dates. ___________________________________________________________________________ ___________________________________________________________________________ 19 Was an automobile registered in the decedent’s name in Accra at any time within five years preceding death? II Yes____ II No____ If yes, give dates. ___________________________________________________________________________ ___________________________________________________________________________ 20 Did the decedent undergo medical treatment or examinations, or was the decedent hospitalized in Accra at any time within five years preceding death? II Yes___ II No___ If

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yes, please furnish names and addresses of the attending physicians and dates admitted or examined. ___________________________________________________________________________ ___________________________________________________________________________ 21 Did the decedent within five years prior to death indicate Accra as home or residence on any government, employment, or similar form? II Yes___ II No___ If yes, provides explanation. ___________________________________________________________________________ ___________________________________________________________________________ 22 Has question of domicile been raised in any jurisdictions for any purpose, i.e. income tax, in the last five years? II Yes___ II No___ If yes, state where, what facts were disclosed and what decision was reached. ___________________________________________________________________________ ___________________________________________________________________________ 23 What other information do you desire to submit in support of the contention that the decedent was not domiciled in Accra at the time of death? ________________________________________________________________________ ________________________________________________________________________ 24 Did decedent within five years of death, transfer property, valued at $500.000 or more, without receiving full financial consideration therefore? I Yes____ I No____ 25 Did decedent at any time, transfer property on terms requiring payment of income to decedent from a source other than such property? I Yes___ I No____ 26 For each transfer, set forth Date of Transfer; Description of Property, Both Real and Personal: Actual Consideration if Any; Names and Relationship to Decedent of Donees, Assignees, Transferees, etc. Market Value at Date of Death __________________________

27 NON- DEDUCTIBLE EXPENSES Contingent liabilities Mortgage, taxes and accrued interest on Storage expense Debts paid by insurance Litigated and disputed claims Local taxes accruing after date of death Transfer Inheritance Tax Administration of Estate Federal Estate Tax 28 .Was decedent a participant in any pension plan that provided for payment of an annuity or lump sum on or after death to another? ___ I Yes ___I No

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29. Did decedent purchase or in any manner participate in any contract or plan providing for payment of an annuity or lump sum on or after death to another, except life insurance contracts payable to a designated beneficiary? ___ I Yes ___ I No (Matured endowment policies, claim settlement certificates, supplementary contracts, annuity contracts and refunds there under and interest income certificates even though issued by an insurance company are not considered life insurance contracts.)

30.Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change because of a reserved power to alter, amend, or revoke, or which could revert to decedent under terms of transfer or by operation of law?.___ I Yes ___ I No If answer to any of the above questions is yes, set forth a description of property transferred the fair market value at date of death, dates of transfers, and to who transferred. Submit copy of trust deed or, agreement, if any. (If transfers are claimed to be untaxable, also submit detailed statement of facts on which such claim is based, proof as to decedent¹s physical condition and copy of death certificate.) Under the penalties of perjury, I declare this affidavit has been examined by me and is, to the best of my knowledge and belief, true, correct and complete.

______________________________________________________________________ Signature of Next of Kin or Administrator

Date-------------------------------------------------

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