Form 1310n - Statement Of Person Claiming Refund Due A Deceased Person
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Statement of Person Claiming
FORM
Refund Due a Deceased Person
1310N
Tax Year
Deceased Person
was Due a Refund
Calendar Year 20
, or Other Tax Year Beginning
and Ending
Name of Deceased Person
Date of Death
Deceased Person’s
Social Security Number
Name of Person Claiming Refund
Claimant’s Social Security Number
Home Address (Number and Street)
City
State
Zip Code
PART I
Check only one box. If you check B or C, you must also complete Part III below.
A
Surviving spouse filing original return with the deceased person.
• Do not file Form 1310N.
• No signature is required for e-filed returns.
• Paper filers, write “surviving spouse” on signature block of Form 1040N.
B
Court-appointed or certified personal representative. Complete Part III and attach a copy of either of the following
with the completed and signed Forms 1040N and 1310N:
• The court order showing proof of appointment; OR
• A copy of the probated will.
All other persons requesting a deceased taxpayer's refund must complete Parts II and III of Form 1310N and
C
attach one of the following:
• Death certificate (need not be certified);
• Newspaper clipping; or
• Department of Defense notification.
PART II
Complete only if you checked Box C, Part I above.
1 Did the deceased person have a will? ...................................................................................
YES
NO
2 a Has a court appointed a personal representative for the estate of the deceased person?
YES
NO
b If you answered “No” to 2a, will one be appointed? .........................................................
YES
NO
NOTE: If you answered “Yes” to 2a or 2b, the personal representative must file for the refund.
3 If you answered “No” to 2b, do you agree to pay out the refund according to the laws of the
state where the deceased person was a legal resident? ......................................................
YES
NO
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 of Form 1310N must complete this part.
I request a refund of taxes overpaid by, or on behalf of, the
deceased
person. Under penalties of perjury, I declare that I have
examined this claim and the attached Nebraska individual income tax return, and to the best of my knowledge and belief, it is true, correct,
and complete.
sign
here
Signature of Person Claiming Refund
Date
Daytime Phone
Print Name
Mail this claim to: NEBRASKA DEPARTMENT OF REVENUE, PO BOX 98911, LINCOLN, NE 68509-8911
, 800-742-7474 (NE and IA), 402-471-5729
8-226-1972 Rev. 10-2011
Supersedes 8-226-1972 Rev. 11-2001
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