Schedule 
        F                 B                   STATEMENT OF CLAIMANT 
   Form IT-140                     TO REFUND DUE DECEASED TAXPAYER                                                    2023
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 certificate 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 certificate 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

                                                                                          *P40202313A*
                                                                                          P40202313A
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