Georgia Deceased Taxpayer Refund Check Claim

Deceased Taxpayer Refund Check Claim
Form GA-5347 
PRINT

CLEAR

Form GA-5347 (Rev. 08/16/18)

Georgia Department of Revenue

Deceased Taxpayer Refund Check Claim Form
Section 1

Complete the information below.

Name of Decedent

Decedent’s Social Security Number

Date of Death

Name of Claimant

Claimant’s Social Security Number

Tax Year of Refund Check

Address of Claimant
Relationship to Decedent:

Section 2

 Administrator/Executor
 Brother/Sister

 Surviving Spouse
 Parent

 Other

Check the ONE box that applies to you after reviewing the instructions. Be sure to sign Section 4.

Line A

□

Surviving spouse requesting reissuance of a refund check. Attach original check & copy of death certificate.

Line B

□

Court-appointed personal representative. Attach original check, copy of death certificate, & court document showing appointment.

Line C

□

Person, other than A or B, claiming refund less than $1,000 for decedent’s estate. Attach original check, copy of death certificate, &
complete Section 3.

Section 3


Complete only if you checked Line C in Section 2.

I am an heir of the decedent and meet the qualifications in the affidavit below. I am claiming this refund, which is less than $1,000, for the
decedent’s estate and have completed the affidavit and had it notarized. I truthfully signed the affidavit and do not need to file to probate or be
appointed a personal representative to claim this refund of taxes.

Claimant’s Affidavit. For collection of personal property in the form of a tax refund check (to be used by heirs of deceased taxpayers).
State of Georgia, __________________________ County
Name of County

I, ___________________________, being duly sworn, affirm that this affidavit is made for the purpose of requesting reissuance of a tax
Full Legal Name

refund check in the amount of $____________ originally issued to __________________________, who died on ___________________.
Amount

Decedent’s Full Legal Name

Date on Death Certificate

I further certify under oath the following (Initial after each statement):
1.
2.

The refund check issued in the decedent’s name is for less than $1,000.
The court has not appointed a personal representative for the estate of the decedent, and no
application/petition for the appointment of a personal representative is pending in any jurisdiction.

3.

I am an heir of the decedent and there are no other heirs of the same or closer degree.

4.

As the person claiming the refund for the decedent’s estate, I will pay out the refund according to
the laws of the state where the decedent was a legal resident at the time of death.

5.

As the claiming heir of the decedent, I am entitled to payment or delivery of the Georgia tax refund.

_________________________________

_________________________________

Signature of Claimant

Printed Name

Notarization. For a public notary to complete.
SEAL

Sworn and subscribed before me this __________ day of ______________________, 20________.

_________________________________

__________________________

Signature of Notary

Notary Commission Expires

Section 4

Signature and Verification. ALL CLAIMANTS must complete this section.

I request a refund of taxes overpaid by or on behalf of the decedent. Under penalties of perjury, I declare that I have examined this claim,
and to the best of my knowledge and belief, it is true, correct, and complete. I understand that to willfully prepare or present a document
that is fraudulent or false is a felony under O.C.G.A. § 16-10-20.

Signature of Claimant:

Date:

General Instructions
Purpose of Form
Use Form GA-5347 to claim a refund on behalf of a
deceased taxpayer.

Who Must File
Only file this form if you need a refund check which was
issued in the deceased taxpayer’s name to be reissued
in the name of the surviving spouse, estate, or
otherwise rightful heir.

Where to File
Mail a completed copy of Form GA-5347 and the
appropriate documents listed below to:
Georgia Department of Revenue
P.O. Box 740389
Atlanta, GA 30374-0389

Personal Representative
For purposes of this form, a personal representative is
the executor or administrator of the decedent’s estate,
as certified or appointed by a court. A copy of the
decedent’s will is not by itself evidence that you are the
personal representative.

Specific Instructions
Section 1 – Decedent & Claimant’s Information
Enter the name, date of death, and social security
number of the decedent.
The claimant must also enter name, address, and
social security number. Make sure to enter this
information accurately, as the Department will send the
reissued refund check to the claimant’s address
entered here.

Section 2 – Claim Type
Line A
Check the box on Line A if you are a surviving spouse
and you received a joint refund check in your and your
deceased spouse’s names. In addition to this form,
you must also attach and send the original joint-name
check and a copy of the death certificate to the address
above. A new check will be issued in your name and
mailed to you.
Line B
Check the box on Line B only if you are the decedent’s
court-appointed personal representative claiming a
refund on behalf of the decedent’s estate. In addition
to this form, you must also attach and send the original

check in the deceased’s name, a copy of the death
certificate, and a copy of the court document showing
your appointment (e.g. Letter of Testamentary or Letter
of Administration) to the address above. A new check
will be issued in the estate’s name and mailed to you.
Line C
Check the box on Line C only if you are not a surviving
spouse claiming a refund based on a joint return and
there is no court-appointed personal representative.
Claimants may only check the box on Line C if the
decedent’s original refund check was for less than
$1,000. For refund checks in amounts equal to or
greater than $1,000, you must check the box on either
Line A or Line B and obtain the appropriate
documentation.
If you qualify as a Line C claimant, complete Section 3.
In addition to this form, you must also attach and send
the original check in the deceased’s name and a copy
of the death certificate to the address above. A new
check will be issued in your name and mailed to you.

Section 3 – Claimant’s Affidavit
Check the box in Section 3 only if you are Line C
claimant. Complete the affidavit and certify that each
statement is true by initialing on the line to the right of
each numbered statement. The affidavit in Section 3
must be notarized by a public notary.

Section 4 – Signature
You must sign in Section 4 for Form GA-5347 to be
effective.