Form R-6642 - Statement Of Claimant To Refund Due On Behalf Of Deceased Taxpayer

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R-6642 (1/16)
Mail to:
Louisiana Department of Revenue
Statement of Claimant to Refund Due on
P.O. Box 4998
Behalf of Deceased Taxpayer
Baton Rouge, La 70821-4998
Phone: 855.307.3893
Fax: 225.219.6220
Date Statement is Executed
Name of Deceased Taxpayer
Taxpayer’s Social Security Number
I, _________________________________________________ hereby certify that I am the ______________________________ of the
(Please Print)
(Relationship or other capacity)
deceased taxpayer and hereby make request for refund of the income taxes overpaid by or in behalf of the decedent.
Note: A certificate of death must accompany this document.
I, the undersigned claimant, certify, under all penalties, fines, and forfeitures imposed by law for the making of false or fraudulent
claims against the State of Louisiana or the making of false statements in connection therewith, declare that if said refund is issued to
him/her, he/she will see that the proceeds thereof are disposed of according to law.
Signature of Claimant
Claimant’s Social Security Number
Address of Claimant
City
State
ZIP

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