New Hampshire  
                           Department of  
                                                               NH-1310                     *NH13102311862*
                  Revenue Administration
                                                                                                          NH13102311862

                                     REQUEST FOR REFUND DUE FOR A DECEASED TAXPAYER

PRINT OR TYPE                                     MMDDYYYY                                      MMDDYYYY
                           Tax Period Begin Date:                           Tax Period End Date:

Name of Decedent                                                     Date of Death (MMDDYYYY)       Taxpayer Identification Number

Number & Street Address ;WĞƌŵĂŶĞŶƚ Žƌ  ŽŵŝĐŝůĞ ŽŶ ƚŚĞ ĚĂƚĞ ŽĨ ĚĞĂƚŚͿ City / Town                    State      Zip Code + 4 ;Žƌ  ĂŶĂĚŝĂŶ WŽƐƚĂů  ŽĚĞͿ

Name of Claimant                                                     Claimant Number & Street Address

City / Town                          State        Zip Code + 4 ;Žƌ  ĂŶĂĚŝĂŶ WŽƐƚĂů  ŽĚĞͿ

I am filing this statement as (check only one box):
A.     Surviving spouse, claiming a refund based on a joint return KZ ƌĞĐĞŝǀĞĚ Ă ũŽŝŶƚ ƌĞĨƵŶĚ ĐŚĞĐŬ ďƵƚ ĂƌĞ ƌĞƋƵĞƐƚŝŶŐ Ă ŶĞǁ ĐŚĞĐŬ ŝŶ LJŽƵƌ ŶĂŵĞ 
         ŽŶůLJ. Attach a copy of the death certificate.
B.        dministrator or executor. Attach a court certificate showing your appointment and death certificate.

 C.      Trustee of the trust. Attach a copy of the certificate of trust, trust affidavit, a copy of the trust, and a copy of the death certificate.

^/'E dhZ   E  s Z/&/  d/KE
I hereby make request for refund of taxes overpaid by or on behalf of the decedent and declare, under penalties of perjury, that I have examined this 
claim and to the best of my knowledge and belief, it is true, correct and complete.

Signature (in ink) of Claimant                                 dŽĚĂLJΖƐ  ĂƚĞ ;DD  zzzzͿ

                                                               INSTRUCTIONS
t,K Dh^d &/>  
/Ĩ LJŽƵ ĂƌĞ ĐůĂŝŵŝŶŐ Ă ƌĞĨƵŶĚ ŽŶ ďĞŚĂůĨ ŽĨ Ă ĚĞĐĞĂƐĞĚ ƚĂdžƉĂLJĞƌ͕ LJŽƵ ŵƵƐƚ ĨŝůĞ &Žƌŵ E,ͲϭϯϭϬ͘ 
WHERE TO FILE 
Mail forms to the New Hampshire Department of Revenue Administration, Taxpayer Services Division, PO Box 3306, Concord, NH 03302-3306. 
FORMS SHALL NOT BE FILED BY FAX OR EMAIL͘
>/E  A 
Check the box on Line A if you are a surviving spouse filing a joint return but requesting a refund in your name only, or if you received a joint refund 
check but are requesting a new check in your name only. For either request, you must include a copy of the death certificate with a completed Form 
NH-1310. If you are requesting a new check in your name only, you must also return the joint refund check with Form NH-1310. 
>/E  B 
Check the box on Line B only if you are the decedent's court-appointed administrator or executor. You must include a copy of the court certificate 
showing your appointment and a copy of the death certificate with the completed Form NH-1310. A copy of the decedent's will cannot be accepted 
as evidence that you are the personal representative. 
>/E  C 
Check the box on Line C only if you are the trustee of the trust. You must file a certificate of trust, trust affidavit, a copy of the trust, and a death 
certificate with the completed Form NH-1310. A copy of the decedent's will cannot be accepted as evidence that you are the personal representative. 
NEED HELP? 
Call the Department of Revenue Administration, Taxpayer Services Division at (603) 230-5920.  Individuals with hearing or speech impairments may 
call TDD Access: Relay NH 1-800-735-2964.
     NH-1310
     sĞƌƐŝŽŶ ϭ   ϴ 0 /202ϯ                                                                                                   Page 1 of 1