Form N-110 - Statement Of Person Claiming Refund Due A Deceased Taxpayer Page 2
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1
2FORM N-110
(REV. 2012)
PAGE 2
court as the personal representative for Mr. Green’s estate and you
attach a copy of the court certificate showing your appointment.
file Form N-11 for Mr. Green. You do not need to file Form N-110
But if you have already sent the court certificate to the Department
to claim the refund on Mr. Green’s tax return. However, you must
of Taxation, complete Form N-110 and write “Certificate Previously
attach to his return a copy of the court certificate showing your
Filed” at the bottom of the form.
appointment.
Line C
Personal Representative
Check the box on line C if you are not a surviving spouse claiming
For purposes of this form, a personal representative is the executor
a refund based on a joint return and there is no court-appointed
or administrator of the decedent’s estate, as certified or appointed
personal representative. You must also complete Part II. If you
by the court. A copy of the decedent’s will cannot be accepted as
check the box on line C, you must attach the proof of death. But
evidence that you are the personal representative.
if you have already sent the proof of death to the Department of
Taxation, complete Form N-110 and write “Proof of Death Previously
Additional Information
Filed” at the bottom of the form.
The proof of death must be an authentic copy of either of the
For more details, see Death of Taxpayer in the Instructions for Form
following:
N-11, N-13, and N-15. Get federal Pub. 559, Survivors, Executors,
and Administrators, for a discussion on this matter.
•
The death certificate, or
•
Specific Instructions
The formal notification from the appropriate government office
(such as, Department of Defense) informing the next of kin of
P.O. Box
the decedent’s death.
State your relationship to the decedent in the space provided.
Enter your box number only if your post office does not deliver mail
to your home.
Example. Your father died on August 25. You are his sole survivor.
Your father did not have a will and the court did not appoint a
Foreign Address – If your address is outside the United States or
personal representative for his estate. Your father is entitled to a
its possessions or territories, enter the information in the following
$300 refund. To get the refund, you must complete and attach
order: City, province or state, and country. Follow the country’s
Form N-110 to your father’s final return. You should check the box
practice for entering the postal code. Do not abbreviate the country
on line C of Form N-110, answer all the questions in Part II, and
name.
sign your name in Part III. You must also attach a copy of the death
certificate or other proof of death. In the space provided, state that
Line A
you are the decedent’s child.
Check the box on line A if you received a refund check in your
name and your deceased spouse’s name. You can return the joint-
Lines 1-3
name check with Form N-110 to the Department of Taxation. A new
If you checked the box on line C, you must complete lines 1 through
check will be issued in your name and mailed to you.
3 in Part II.
Line B
Check the box on line B only if you are the decedent’s court-
appointed personal representative claiming a refund for the
decedent on an amended individual income tax return. You must
MAILING ADDRESS
Hawaii Department of Taxation
P. O. Box 3559
Honolulu, Hawaii 96811-3559
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