Form 1310n - Statement Of Person Claiming Refund Due A Deceased Person
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1
2Statement of Person Claiming
FORM
Refund Due a Deceased Person
1310N
Before You Begin: If you are a surviving spouse filing a joint return with the deceased person, do not file Form 1310N.
Paper filers, write “surviving
spouse”
on the signature block of Form 1040N or 1040XN.
Tax Year
Deceased Person
was Due a Refund
Calendar Year 20
, or Other Tax Year Beginning
/
/
and Ending
/
/
Name of Deceased Person
Date of Death
Deceased Person’s
Social Security Number
Name of Person Claiming Refund (Claimant)
Claimant’s Social Security Number
Home Address (Number and Street)
City
State
Zip Code
Part I
Check only one box. If you check box C, you must also complete Part II below.
A
Surviving spouse requesting reissuance of a refund check (see instructions).
B
Court-appointed or certified personal representative (defined below). Attach a court certificate showing your
appointment (see instructions).
C
All other persons requesting a deceased taxpayer’s refund. Complete Parts II and III below and attach a copy of
one of the following:
• Death certificate (need not be certified); or
• Formal notification from the appropriate government office (for example, Department of Defense, Department of
Health and Human Services, Department of State, etc.) informing the next of kin of the deceased person’s death.
Part II
Complete only if you checked Part I, box C above.
1 Did the deceased person have a will?...................................................................................
YES
NO
2 a Has a court appointed a personal representative for the estate of the deceased person?
YES
NO
b If you answered “No” to 2a, will one be appointed? .........................................................
YES
NO
Note: If you answered “Yes” to either 2a or 2b, the personal representative must file for the refund.
3 As the claimant, do you agree to pay out the refund according to the laws of the state
where the deceased person was a legal resident? ...............................................................
YES
NO
If you answered “No” to 3, a refund cannot be made until you submit a court certificate showing your appointment as
personal representative or other evidence that you are entitled under state law to receive the refund.
Part III
Signature and verification. All claimants must complete this.
I request a refund of taxes overpaid by, or on behalf of, the
deceased
person. Under penalties of perjury, I declare that I have examined
this claim and the attached Nebraska individual income tax return, and to the best of my knowledge and belief, it is true, correct, and complete.
sign
(
)
here
Signature of Claimant
Date
Daytime Phone
Print Name
Mail this claim to: Nebraska Department of Revenue, PO Box 98911, Lincoln, NE 68509-8911.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
8-226-1972 Rev. 9-2016
Supersedes 8-226-1972 Rev. 11-2014
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