Schedule 
              F             B                      STATEMENT OF CLAIMANT 
     Form IT-140                           TO REFUND DUE DECEASED TAXPAYER
                                                                                                                        2022
Attach completed schedule to decedent’s return
  NAME OF                                                                   NAME OF 
  DECEDENT                                                                  CLAIMANT
  DATE OF                     SOCIAL SECURITY                               SOCIAL SECURITY 
  DEATH                       NUMBER                                        NUMBER
  ADDRESS
  (permanent residence or                                                   ADDRESS
  domicile at date of death)
  CITY                            STATE            ZIP                        CITY                      STATE           ZIP 
                                                   CODE                                                                 CODE

I am  filing this statement as (check only one box):
A.     Surviving wife or husband, claiming a refund based on a joint return                                     ATTACH A LIST TO THIS SCHED-
                                                                                                                ULE CONTAINING THE NAME 
B.     Administrator or executor. Attach a court certi ficate showing your appointment.                          AND ADDRESS OF THE SURVIV-
                                                                                                                ING SPOUSE AND CHILDREN OF 
C.     Claimant for the estate of the decedent, other than above. Complete the rest of this schedule and attach     THE DECEDENT.
       a copy of the death certi ficate or proof of death*
                                  TO BE COMPLETED ONLY IF BOX C ABOVE IS CHECKED
                                                                                                                                                                                                           YES NO

  1. Did the decedent leave a will?....................................................................................................................................................................

  2(a).Has an administrator or executor been appointed for the estate of the decedent?......................................................................................

  2(b) If "NO" will one be appointed?......................................................................................................................................................................
     If 2(a) or 2(b) is checked "YES", do not  file this form. The administrator or executor should  file for the refund. 

  3. Will you, as the claimant for the estate of the decedent, disburse the refund according to the laws of the state in which the decedent 
     was domiciled or maintained a permanent residence?.................................................................................................................................
     If "NO", payment of this claim will be withheld pending submission of proof of your appointment as administrator or execu-
     tor or other evidence showing that you are authorized under state law to receive payment.

                                                   SIGNATURE AND VERIFICATION
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 of claimant _____________________________________________________   Date _______________________________

*May be the original of an authentic copy of a telegram or letter from the Division of Defense notifying the next of kin of death while in 
active service, or a death certificate issued by the appropriate officer of the Division of Defense.

                                                                                            *P40202215A*
                                                                                            P40202215A
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