Form 5347 - Statement Of Person Claiming Refund On Behalf Of A Deceased Taxpayer
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1
2Statement of Person Claiming
5347
Georgia Department of Revenue
Form
Refund on Behalf of a Deceased Taxpayer
(Rev. 09/04)
Taxpayer Services Division
See instructions 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
type
or
Home address (number and street). If you have a P. O. box, see instructions
Apt. no.
print
City, town or post office, state, and ZIP code. If you have a foreign address, see instructions.
Relationship of Claimant:
Administrator/Executor
Surviving Spouse
Brother/Sister
Parent
Other
Part I
Check the box that applies to you. Check only one box. Be sure to complete Part IV below.
A
Surviving spouse requesting reissuance of a refund check (see instructions).
B
Court-appointed or certified personal representative. Attach a court certificate showing your appointment, unless previously
filed (see instructions).
C
Person, other than A or B, claiming refund for the decedent’s estate (see instructions). Also, complete Part II and Part III.
Part II
Complete this part only if you checked the box on line C in Part I.
Yes
No
1 Did the decedent leave a will? .............................................................................................................................
2a Has a court appointed a personal representative for the estate of the decedent? .................................................
b If you answered “No” to 2a, will one be appointed? ............................................................................................
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
If you answered “Yes” to 2a or 2b, the personal representative must file for the refund.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
3 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 appoint-
ment as personal representative or other evidence that you are entitled under state law to receive the refund.
Part III
Complete this part if you checked the box on line C in Part I. Attach a separate sheet if necessary.
The decedent was survived by the following: (List name and address for each. Write “None” where applicable.)
Name
Address
Age
Guardian (If under age 18)
Spouse:
Child(ren):
Parent(s):
Father
Mother
Brother/Sister:
Part IV
Signature and Verification. All filers must complete this part.
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
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