Form 1310N Fillable Statement of Person Claiming Refund Due a Deceased Taxpayer  (11/2014)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

8 226 1972 Rev 11 2014 A copy of the probated will b If you answered No to 2a will one be appointed? YES NO City State Zip Code Death certificate (need not be certified); or Example Mr Brown died on August 23 His son is his sole survivor Mr Brown did not have a will and the court Formal notification from the appropriate government office (for example Department of Defense Department of Home Address (Number and Street) I request a refund of taxes overpaid by or on behalf of the deceased person Under penalties of perjury I declare that I have examined If you answered No to 3 a refund cannot be made until you submit a court certificate showing your appointment as Lincoln Nebraska 68509 8911 Name of Deceased Person Date of Death Deceased Person s Social Security Number Name of Person Claiming Refund Claimant s Social Security Number Nebraska Department of Revenue Note: If you answered Yes to either 2a or 2b the personal representative must file for the refund one of the following: P An administrator of the deceased person s estate as certified or appointed by the court P An executor; or P Copy of the deceased person s probated will P Court order; or P Death certificate (need not be certified); or P The formal notification from the appropriate government office (for example Department of Defense Department of personal representative or other evidence that you are entitled under state law to receive the refund PO Box 98911 Print Name Signature of Person Claiming Refund Date Daytime Phone state where the deceased person was a legal resident? YES NO The court order showing proof of appointment; or 1 Did the deceased person have a will? YES NO 1310N 2 a Has a court appointed a personal representative for the estate of the deceased person? YES NO 3 If you answered No to 2b do you agree to pay out the refund according to the laws of the A new check will be issued solely in your name and mailed to you A Surviving spouse requesting reissuance of a refund check (see instructions) and there is no court appointed or certified personal representative Claimants may be any person in charge of the deceased appointment as described above must be attached to the return being filed Complete Part III Attach a copy of the following forms of proof of death: B Court appointed or certified personal representative Complete Part III below and attach a copy of one of the be attached to Form 1040N or 1040XN Proof of appointment may include a copy of: Before You Begin: If you are a surviving spouse filing a joint return with the deceased person do not file Form 1310N C All other persons requesting a deceased taxpayer s refund Complete Parts II and III below and attach a copy of Calendar Year 20 or Other Tax Year Beginning and Ending certified personal representative claiming a refund for the deceased person on Form 1040N or Form 1040XN A copy of your Check only one box If you check box C you must also complete Part II below Complete only if you checked Part I box C above death certificate or other proof of death deceased person s Nebraska Individual Income Tax Return Form 1040N or 1040XN and mail to: did not appoint a personal representative for his estate Mr Brown was entitled to a $330 refund To receive the documentation is not received with the return the Department may request the required documentation during the processing following with the completed and signed Form 1040N or 1040XN: Form 1310N answer all the questions in Part II and sign his own name in Part III He must also attach a copy of the Health and Human Services Department of State etc ) informing the next of kin of the decedent s death if you are a surviving spouse filing a married filing jointly return with the deceased person If you are filing a paper income tax return you must attach Form 1310N and any other required documentation to the If you have already sent proof of death to the Department write Proof of Death Previously Filed at the bottom of the form Instructions Mail this claim to: Nebraska Department of Revenue PO Box 98911 Lincoln NE 68509 8911 may be submitted as an attached PDF document if your software supports these types of attachments If the supporting name You can return the joint name check with Form 1310N to: of your return This may result in a delayed refund Paper filers write surviving spouse on the signature block of Form 1040N or 1040XN Part I Part I Box A Surviving Spouse Check box A if you received a refund check in your name and your deceased spouse s Part I Box B Personal Representative Check box B only if you are the deceased person s court appointed or Part I Box C All Other Persons Check box C if you are not a surviving spouse claiming a refund based on a joint return Part II Part II Lines 1 3 If you check box C you must complete lines 1 through 3 of Part II Part III Part III All filers of Form 1310N must complete this person s affairs Complete Parts II and III Personal Representative For purposes of this form a personal representative includes: Refund Due to a Deceased Person refund his son must complete and attach Form 1310N to his father s final income tax return He must check box C of revenue nebraska gov 800 742 7474 (NE and IA) 402 471 5729 Signature and verification All filers of Form 1310N must complete this Specific Information Statement of Person Claiming Supersedes 8 226 1972 Rev 11 2013 Tax Year Deceased Person was Due a Refund this claim and the attached Nebraska individual income tax return and to the best of my knowledge and belief it is true correct and complete Trust agreements or affidavits for transfer of personal property are not accepted When a person claiming a refund is the personal representative of the deceased person s estate proof of appointment must When and Where to File If you are e filing the income tax return Form 1310N and required supporting documentation when filing Form 1310N Who Must File File Form 1310N if you are claiming a refund on behalf of a deceased person Do Not file Form 1310N