New Hampshire  
                            Department of  
                                                                NH-1310                  *NH13102411862*
                      Revenue Administration
                                                                                                     NH13102411862

                                           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 Ă ĐŽƉLJ ŽĨ ƚŚĞ death certificate.
 C. Trustee of the trust. Attach a copy of the certificate of trust, a copy of the trust, and a copy of the death certificate. dŚĞ ƌĞƚƵƌŶ 
    ƌĞƋƵĞƐƚŝŶŐ ƚŚĞ ƌĞĨƵŶĚ ŵƵƐƚ ŚĂǀĞ ďĞĞŶ ĨŝůĞĚ ŝŶ ƚŚĞ ŶĂŵĞ ŽĨ Ă ƚƌƵƐƚ ĨŽƌ ƚŚĞ ƌĞĨƵŶĚ ƚŽ ďĞůŽŶŐ ƚŽ ƚŚĂƚ ƚƌƵƐƚ͕ Žƌ LJŽƵ ŵƵƐƚ ƉƌŽĚƵĐĞ Ă ĐŽƵƌƚ 
    ŽƌĚĞƌ Žƌ ŽƚŚĞƌ ĞǀŝĚĞŶĐĞ ƚŚĂƚ ƚŚĞ ƌĞĨƵŶĚ ďĞůŽŶŐƐ ƚŽ ƚŚĞ ƚƌƵƐƚ͘

  . WĞƌƐŽŶ͕ ŽƚŚĞƌ ƚŚĂŶ  ͕  ͕ Žƌ  ͘  ŽŵƉůĞƚĞ ƋƵĞƐƚŝŽŶƐ ďĞůŽǁ͘ 
                  ϭ͘  ŝĚ ƚŚĞ ĚĞĐĞĚĞŶƚ ůĞĂǀĞ Ă ǁŝůů͍ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ zĞƐ        EŽ
                  ϮĂ͘ ,ĂƐ Ă ĐŽƵƌƚ ĂƉƉŽŝŶƚĞĚ Ă ƉĞƌƐŽŶĂů ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ ĨŽƌ ƚŚĞ ĞƐƚĂƚĞ ŽĨ ƚŚĞ ĚĞĐĞĚĞŶƚ͍ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘                                  zĞƐ        EŽ
                  Ϯď͘ /Ĩ LJŽƵ ĂŶƐǁĞƌĞĚ ΗEŽΗ ƚŽ ƋƵĞƐƚŝŽŶ ϮĂ͕ ǁŝůů ŽŶĞ ďĞ ĂƉƉŽŝŶƚĞĚ͍ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘                       zĞƐ        EŽ
                      /Ĩ LJŽƵ ĂŶƐǁĞƌĞĚ ΗzĞƐΗ ƚŽ ƋƵĞƐƚŝŽŶ ϮĂ Žƌ Ϯď͕ ƚŚĞ ƉĞƌƐŽŶĂů ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ ŵƵƐƚ ĨŝůĞ ĨŽƌ ƚŚĞ ƌĞĨƵŶĚ͘ 
                  ϯ͘  Ɛ ƚŚĞ ƉĞƌƐŽŶ ĐůĂŝŵŝŶŐ ƚŚĞ ƌĞĨƵŶĚ ĨŽƌ ƚŚĞ ĚĞĐĞĚĞŶƚΖƐ ĞƐƚĂƚĞ͕ ǁŝůů LJŽƵ ƉĂLJ ŽƵƚ ƚŚĞ ƌĞĨƵŶĚ ĂĐĐŽƌĚŝŶŐ ƚŽ ƚŚĞ ůĂǁƐ ŽĨ
                    ƚŚĞ ^ƚĂƚĞ ǁŚĞƌĞ ƚŚĞ ĚĞĐĞĚĞŶƚ ǁĂƐ Ă ůĞŐĂů ƌĞƐŝĚĞŶƚ͍ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘                zĞƐ        EŽ
                    /Ĩ LJŽƵ ĂŶƐǁĞƌĞĚ ΗEŽΗ ƚŽ ƋƵĞƐƚŝŽŶ ϯ͕ Ă ƌĞĨƵŶĚ ĐĂŶŶŽƚ ďĞ ŵĂĚĞ ƵŶƚŝů LJŽƵ ƐƵďŵŝƚ Ă ĐŽƵƌƚ ĐĞƌƚŝĨŝĐĂƚĞ ƐŚŽǁŝŶŐ LJŽƵƌ 
                    ĂƉƉŽŝŶƚŵĞŶƚ ĂƐ ƉĞƌƐŽŶĂů ƌĞƉƌĞƐĞŶƚĂƚŝǀĞ Žƌ ŽƚŚĞƌ ĞǀŝĚĞŶĐĞ ƚŚĂƚ LJŽƵ ĂƌĞ ĞŶƚŝƚůĞĚ ƵŶĚĞƌ ƐƚĂƚĞ ůĂǁ ƚŽ ƌĞĐĞŝǀĞ ƚŚĞ 
                    ƌĞĨƵŶĚ͘ 

^/'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

    E,ͲϭϯϭϬ
    sĞƌƐŝŽŶ ϭ   Ϭϭ  /202ϰ                                                                                                                                                                     Page 1 of 1