Form 804 - Claim For Decedent'S Wisconsin Income Tax Refund

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804
Claim for Decedent’s
Address Mail To:
Form
Wisconsin Income Tax Refund
Tax Operations Bureau
MS 3-164
Wisconsin Department
PO Box 8903
Madison WI 53708-8903
of Revenue
See instructions below and on back.
Tax year decedent was due a refund:
Calendar year
, or other tax year beginning
, 20
, and ending
, 20
Name of Decedent
Date of Death
Decedent’s Social Security Number
Name of Person Claiming Refund
Your Social Security Number
Please
print
Home Address (number and street).
Apt. No.
or
type
City, Town or Post Office, State, and Zip Code. If you have a foreign address, see instructions.
Part I
Check the box that applies to you. Check only one box. Be sure to complete Part II below.
Relationship to decedent:
Court-appointed or certified personal representative. Attach a domiciliary letter showing your appointment, un-
less previously filed (see instructions).
Claims will be given preference to relatives in the following order:
1. Surviving spouse
2. Child
3. Parent
4. Brother or sister
5. Creditor of decedent
Signature and verification.
Part II
I request a refund of taxes overpaid by or on behalf of the decedent. Under penalties of perjury, I declare that I have examined this claim, and to the best
of my knowledge and belief, it is true, correct, and complete.
Signature of Person Claiming Refund
Date
Where To File
General Instructions
Send this completed and signed form along with the
decedent’s refund check to:
Purpose of Form
Use Form 804 to claim a refund on behalf of a deceased
Tax Operations Bureau
taxpayer.
Mail Stop 3-164
PO Box 8903
Who Must File
Madison WI 53708-8903
If you are claiming a refund on behalf of a deceased tax-
payer, you may be required to file Form 804.
Personal Representative
For purposes of this form, a personal representative is
If you are unable to cash the refund check that was sent
the executor or administrator of the decedent’s estate,
to you, you should return it with a completed Form 804. If
as appointed or certified by the court. A copy of the dece-
you are a personal representative, you should also attach
dent’s will cannot be accepted as evidence that you are
your domiciliary letter showing your appointment.
the personal representative.
I-804 (R. 9-11)

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