Statement Of Person Claiming Refund Due A Deceased Taxpayer


Utah State Tax Commission
Statement of Person Claiming Refund Due a Deceased Taxpayer
Rev. /12
See instructions on the reverse aside.
Enter the tax year the decedent was due a tax refund: ________________
Name of decedent (primary taxpayer if joint return)
Date of death
Decedent's social security number
Name of person claiming refund
Relationship to decedent
Telephone number
ZIP Code
Check the box that applies to you. Check only one box.
I am the court appointed personal representative of the decedent's estate, request a refund of taxes overpaid by or on behalf of the decedent,
and have attached a copy of the court document showing my appointment.
Under penalty of perjury, I declare I have examined this claim, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of court-appointed or certified representative
I am a successor (heir) of the decedent and meet the qualifications in the affidavit below and am claiming any refund for the decedent's estate.
I have completed the affidavit below and had it notarized. I truthfully signed the affidavit and do not need to file a probate and be appointed a
personal representative to claim this refund of taxes.
For collection of personal property pursuant to small estate proceeding in accordance with U.C. 75-3-1201 and 1202
(to be used by heirs of deceased taxpayers)
State of Utah
County of
, being sworn, state that:
(your name)
1. This affidavit is made for the purpose of collecting personal property (in the form of a tax refund) of
who died on
(name of decedent)
2. I make this affidavit as successor of the decedent or representative of successor.
3. The value of the decedent's entire estate subject to administration, wherever located, excluding liens and encumbrances, does
not exceed one hundred thousand dollars.
4. At least thirty days have elapsed since the death of the decedent.
5. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.
6. As the claiming successor of the decedent, I am entitled to payment or delivery of the state tax refund, plus applicable interest.
Place notary stamp in space below
Subscribed and sworn to before me on
this ______ day of _____________________ 20______
by __________________________________________
Signature of affidavit (survivor)
Notary signature


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