Other 4Specify Did the deceased leave a will?
Spouse/domestic partner Off
Yes Off
2012 FR 147
a Deceased Taxpayer *121470110002*
Administrator
Attach this form to the deceased s D 40 along with a copy of the death certificate or other proof of death
City State Zip code +4
Claiming Refund Due
Deceased s social security number Date of death (MM/DD/YY)
District of Columbia
ExecutorOff
Fill in only one:Off
FR 147 Statement of Person l
Government of the
Has an executor or administrator been appointed for the estate?Off
I have examined this claim and to the best of my knowledge it is correct
If no a refund cannot be made until you submit a court certificate showing your appointment as personal representative or other evidence that you are entitled under DC law to receive the refund
If no will one be appointed? Yes No
If other than the deceased who paid deceased s 2012 DC income tax?
If you are filing as an administrator or executor attach a copy of the court certificate of appointment
Name Claimant s SSN
OFFICIAL USE ONLY
OffOff
Personal information
Relationship to deceased
Revised 03/2012
Signature I request a refund of DC income tax overpaid by or on behalf of the deceased Under penalties of law I declare that
Statement of Claimant
Statement of Person Claiming Refund Due a Deceased Taxpayer
This is a FILL IN format Please do not handwrite any data on this form other than your signature
Vendor ID# 0002
Will you pay out the refund to beneficiaries according to the laws of the state where the deceased was a legal resident?
Your First name M I Last name
Your home address (number and street)
Your relationship to the deceased
Your signature Date
