Form FR-147 Statement of Person Claiming Refund Due a Deceased Taxpayer

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