Form Dr 0102 - Claim For Refund On Behalf Of Deceased Taxpayer
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DR 0102 (07/25/13)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Claim for Refund on
Behalf of Deceased Taxpayer
Surviving spouses and legal representatives for
Complete the form below only if the return results
someone who died during the year may file a return
in a refund, and mail separately and apart from the
on the deceased’s behalf. Write “deceased” in large
return itself. You must also submit a copy of the
death certificate to this form before mailing.
letters across the top of the return, check the box after
the deceased person’s name and write the date of death.
Additionally, you must sign the return and write “filing
as surviving spouse” or “filing as legal representative”
by your signature.
Claim for refund cannot be processed if this information is not complete.
Death certificate must accompany this completed form.
Deceased Taxpayer Last Name
First Name
Middle Initial
Address (permanent residence on the date of death)
SSN
City
State
Zip
Date of Death
(MM/DD/YY)
Last Name of Person Filing Claim (claimant)
First Name
Middle Initial
Address
City
State
Zip
I am filing this statement as (mark only one box)
A.
Surviving wife or husband
Personal representative, executor or administrator. Attach a court certificate showing your appointment.
B.
C.
Claimant for the estate of the decedent where there is no court estate proceeding.
Relationship with deceased taxpayer (must be completed if Box C is checked)
Signature and Verification
I hereby make request for refund of taxes overpaid by or on behalf of the deceased taxpayer and declare under
penalties of perjury in the second degree 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
(MM/DD/YY)
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