Form 243 - Claim To Refund Due A Deceased Person
ADVERTISEMENT
1FORM
CLAIM TO REFUND DUE A DECEASED PERSON
FOR OFFICE USE ONLY
243
Date Received
For Calendar Year ________
(or other taxable year beginning __________________, _______ and ending __________________, _______ )
•Please attach a photocopy of the death certificate.
Name of Decedent
Name of Claimant
Date of Death
*
Claimant’s Social Security Number
Telephone Number
Decedent’s Social Security Number
Street Address
Street Address (permanent residence or domicile on date of death)
City
State
ZIP Code
City
State
ZIP Code
Claimant: If you have the original refund check, send it back with this form.
1. (a) Has a personal representative for the estate been appointed by the court?
. . . . . . . . . . . . . . . .
Yes
No
Yes
No
(b) If “No” will one be appointed?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: If 1(a) or 1(b) is “Yes” the personal representative must claim the refund.
Yes
No
2. Has a Small Estate Affidavit been filed with the county clerk? (ORS 114.515)
. . . . . . . . . . . . . . . . .
Note: If 2 is “Yes” the responsible party on the Small Estate Affidavit must claim the refund.
Yes
No
3. Has the probate or small estate closed?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: If 3 is “Yes” claimant from Schedule A below must claim the refund.
4. Does the total due the decedent (except for salary or wages) from all State of Oregon
Yes
No
agencies exceed $10,000?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: If 4 is “Yes” you must file a Small Estate Affidavit or open a probate to receive the refund.
5. I am filing this statement as (check one box only):
(a)
Personal representative of estate. (Attach a copy of court appointment.)
(b)
Responsible party filing Small Estate Affidavit. (ORS 114.515) (Attach a copy of the affidavit.)
(c)
Claimant other than above. Complete Schedule A.
Note: Only claimants listed above, or in Schedule A qualify.
Schedule A
(To be completed only if 5(c) above is checked.)
I (we) promise to use all of the money to pay the expenses of the last illness and funeral of the decedent if necessary. If,
after payment by the State Treasurer, the decedent’s estate is probated, I (we) promise to account fully to the personal
representative.
I (we) qualify for payment under ORS 293.490 and 293.495 as (check one box only):
Surviving spouse.
Trustee of revocable inter vivos trust created by the decedent.
Children of the decedent, or children of a deceased child of the decedent.
Parents of the decedent.
Brothers and/or sisters of the decedent.
Nephews and/or nieces of the decedent.
Note: If Schedule A is completed, all persons in the group of eligible claimants must sign below. Attach a separate sheet if necessary.
Signature and Verification
There are no survivors in the claimant’s kinship group except those who have signed below, and there are no kin who are
more closely related to the decedent.
I (we) declare under the penalties of false swearing that the above statements are true. I (we) agree to the Oregon
Department of Revenue issuing the check to the claimant named above.
Signature
Signature
X
X
Social Security Number
Date
Date
Social Security Number
*Social Security number is required for identification purposes. OAR 150-305.100.
Return this form to: Oregon Department of Revenue
955 Center Street NE
Salem OR 97310-2501
150-101-032 (Rev. 9-99)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial