Form N-110 - Statement Of Person Claiming Refund Due A Deceased Taxpayer

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FORM

STATE OF HAWAII — DEPARTMENT OF TAXATION

N-110

Statement of Person Claiming

(REV. 2012)

Refund Due a Deceased Taxpayer

For Calendar Year

or other taxable year beginning

, and ending

(NOTE: References to “married”, “unmarried”, and “spouse” also means in a “civil union”, “not in a civil union”, and “civil union partner”, respectively.)

Name of decedent

Date of death

Decedent’s Social Security Number

Please

Name of person claiming refund

Your Social Security Number

type

Home address (number and street). If you have a P.O. box, see instructions.

Apt. No.

City, town, or post office, state and Postal/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 III below.



Surviving spouse requesting reissuance of a refund check. See instructions.



Court-appointed or certified personal representative. Attach a court certificate showing your appointment, unless previously

filed. See instructions.



Person, other than A or B, claiming refund for the decedent’s estate. Also, complete Part II. Attach a copy of the proof of

death, unless previously filed. See instructions.

State your relationship to the decedent

Part II

Complete this part only if you checked the box on line C above.

YES NO

Did the decedent leave a will? ..............................................................................................................................................

(a) Has a court appointed a personal representative for the estate of the decedent? .........................................................

(b) If you answered “No” to 2(a), will one be appointed? .....................................................................................................

If you answered “Yes” to 2(a) or 2(b), the personal representative must file for the refund.

As the person claiming the refund for the decedent’s estate, will you pay out the refund according to the laws

of the state where the decedent was a legal resident? ........................................................................................................

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 filers must complete this part.

I hereby make a request for refund of taxes overpaid by or on behalf of the decedent and declare under penalties set forth in section

231-36, HRS, that I have examined this claim and to the best of my knowledge and belief, it is true, correct, and complete.

Signature of claimant

Date

Who Must File

General Instructions

If you are claiming a refund on behalf of a deceased taxpayer, you

NOTE: Effective January 1, 2012, civil unions are recognized in