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Schedule
5 F B STATEMENT OF CLAIMANT 5
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Form IT-140 TO REFUND DUE DECEASED TAXPAYER 2023
7 Attach completed schedule to decedent’s return 7
8 NAME OF NAME OF 8
9 DECEDENT CLAIMANT 9
10 DATE OF SOCIAL SECURITY SOCIAL SECURITY 10
11 DEATH NUMBER NUMBER 11
12 ADDRESS 12
13 (permanent residence or ADDRESS 13
domicile at date of death)
14 CITY STATE ZIP CITY STATE ZIP 14
15 CODE CODE 15
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17 I am filing this statement as (check only one box): 17
18 A. Surviving wife or husband, claiming a refund based on a joint return ATTACH A LIST TO THIS SCHED- 18
ULE CONTAINING THE NAME
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B. Administrator or executor. Attach a court certificate showing your appointment. AND ADDRESS OF THE SURVIV-
20 ING SPOUSE AND CHILDREN OF 20
21 C. Claimant for the estate of the decedent, other than above Complete the rest of this schedule and attach THE DECEDENT. 21
22 a copy of the death certificate or proof of death* 22
23 TO BE COMPLETED ONLY IF BOX C ABOVE IS CHECKED 23
24 YES NO 24
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26 1 Did the decedent leave a will? 26
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28 2(a)Has an administrator or executor been appointed for the estate of the decedent? 28
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30 2(b) If "NO" will one be appointed? 30
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If 2(a) or 2(b) is checked "YES", do not file this form. The administrator or executor should file for the refund.
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33 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 33
34 was domiciled or maintained a permanent residence? 34
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If "NO", payment of this claim will be withheld pending submission of proof of your appointment as administrator or execu-
36 tor or other evidence showing that you are authorized under state law to receive payment. 36
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39 SIGNATURE AND VERIFICATION 39
40 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 40
41 examined this claim and to the best of my knowledge and belief, it is true, correct and complete 41
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47 Signature of claimant _____________________________________________________ Date _______________________________ 47
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*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
50 active service, or a death certificate issued by the appropriate officer of the Division of Defense 50
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*P40202313A*
63 P40202313A 63
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