Colorado Deceased Taxpayer - Claim for Refund

Deceased Taxpayer - Claim for Refund
Form DR 0102
*140102==19999*

DR 0102 (05/30/17)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
www.TaxColorado.com

Claim for Refund on
Behalf of Deceased Taxpayer
Surviving spouses and legal representatives for
someone who died during the year may file a return on
the deceased’s behalf. Write “deceased” in large letters
across the top of the return, check the box after the
deceased person’s name and write the date of death.
Additionally, you must sign the return and write “filing as
surviving spouse” or “filing as legal representative” by
your signature.

Complete the form below only if the return results in a
refund, and mail with your income tax return for the year.
You must also submit a copy of the death certificate to
this form before mailing.

Claim for refund cannot be processed if this information is not complete.
Death certificate must accompany this completed form.
Deceased Taxpayer Last Name

First Name

Address (permanent residence on the date of death)

Middle Initial
SSN

City

State

Last Name of Person Filing Claim (claimant)

First Name

Address

City

Zip

Date of Death (MM/DD/YY)
Middle Initial
State

Zip

I am filing this statement as (mark only one box)
	A.	

	

Surviving wife or husband

	B.	

	

Personal representative, executor or administrator. Attach a court certificate showing your appointment.

	C.	

	

Claimant for the estate of the decedent where there is no court estate proceeding.

Relationship with deceased taxpayer (must be completed if Box C is checked)

Signature and Verification
I hereby make request for refund of taxes overpaid by or on behalf of the deceased taxpayer and declare under
penalties of perjury in the second degree 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 (MM/DD/YY)