Hawaii Statement of Person Claiming Refund Due to a Deceased Taxpayer

Statement of Person Claiming Refund Due to a Deceased Taxpayer
Form N-110, Rev 2018, Statement of Person Claiming Refund Due a Deceased Taxpayer
Clear Form

FORM

STATE OF HAWAII — DEPARTMENT OF TAXATION

(REV. 2018)

Statement of Person Claiming
Refund Due a Deceased Taxpayer

N-110

	
or other taxable year beginning 	

For Calendar Year
, 		

    
, and ending 	

, 	

(NOTE: References to “married” and “spouse” are also references to “in a civil union,” and “civil union partner,” respectively.)
Name of decedent		

Please
type
or
print

Date of death	

Decedent’s Social Security Number

Name of person claiming refund			

Your Social Security Number

Home address (number and street). If you have a P.O. box, see instructions.			

Apt. No.

City, town, or post office, state and Postal/ZIP code. If you have a foreign address, see instructions.

Part I
A	
B	

	Surviving spouse requesting reissuance of a refund check. See instructions.
	Court-appointed or certified personal representative. Attach a court certificate showing your appointment, unless previously
	

C	

Check the box that applies to you. Check only one box. Be sure to complete Part III below.

filed. See instructions.

	Person, other than A or B, claiming refund for the decedent’s estate. Also, complete Part II. Attach a copy of the proof of
	
	

death, unless previously filed. See instructions.
State your relationship to the decedent                                              

Part II Complete this part only if you checked the box on line C above.	

YES	NO

1	 Did the decedent leave a will?...............................................................................................................................................
2	 (a)	 Has a court appointed a personal representative for the estate of the decedent?..........................................................
	 (b)	 If you answered “No” to 2(a), will one be appointed?......................................................................................................
		 If you answered “Yes” to 2(a) or 2(b), the personal representative must file for the refund.
3	 As the person claiming the refund for the decedent’s estate, will you pay out the refund according to the laws
of the state where the decedent was a legal resident?.........................................................................................................
If you answered “No” to 3, 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 State law, to receive the refund.

Part III Signature and verification. All filers must complete this part.
I hereby make a request for refund of taxes overpaid by or on behalf of the decedent and declare under penalties set forth in section
231-36, HRS, 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 	

General Instructions

Who Must File

NOTE: Hawaii’s laws that apply to a husband and wife, spouses,
or person in a legal marital relationship shall be deemed to apply
to partners in a civil union with the same force and effect as if they
were “husband and wife,” “spouses,” or other terms that describe
persons in a legal marital relationship.

If you are claiming a refund on behalf of a deceased taxpayer, you
must file Form N-110 unless either of the following applies:

Purpose of Form
Use Form N-110 to claim a refund on behalf of a deceased taxpayer.

•	

You are a surviving spouse filing an original or amended joint
return with the decedent, OR

•	

You are a personal representative (as discussed below) filing
an original Form N-11 or N-15 for the decedent and a court
certificate showing your appointment is attached to the return.

Example. Assume Mr. Green died on January 4 before filing his
tax return. On April 3 of the same year, you were appointed by the
court as the personal representative for Mr. Green’s estate and you
(Continued on back)
FORM N-110

N110_I 2018A 01 VID01

ID NO 01

FORM N-110
(REV. 2018)													PAGE 2
file Form N-11 for Mr. Green. You do not need to file Form N-110
to claim the refund on Mr. Green’s tax return. However, you must
attach to his return a copy of the court certificate showing your
appointment.

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 the court. A copy of the decedent’s will cannot be accepted as
evidence that you are the personal representative.

Additional Information

you have already sent the court certificate to the Department of
Taxation, complete Form N-110 and write “Certificate Previously
Filed” at the bottom of the form.

Line C
Check the box on line C if you are not a surviving spouse claiming
a refund based on a joint return and there is no court-appointed
personal representative. You must also complete Part II. If you
check the box on line C, you must attach the proof of death. If you
have already sent the proof of death to the Department of Taxation,
complete Form N-110 and write “Proof of Death Previously Filed”
at the bottom of the form.

For more details, see Death of Taxpayer in the instructions for Form
N-11 and N-15. See federal Publication 559, Survivors, Executors,
and Administrators, for a discussion on this matter.

The proof of death must be an authentic copy of either of the
following:
•	

The death certificate, or

Specific Instructions

•	

The formal notification from the appropriate government office
(such as, Department of Defense) informing the next of kin of
the decedent’s death.

P.O. Box
Enter your box number only if your post office does not deliver mail
to your home.
Foreign Address – If your address is outside the United States or
its possessions or territories, enter the information in the following
order: City, province or state, and country. Follow the country’s
practice for entering the postal code. Do not abbreviate the country
name.

Line A
Check the box on line A if you received a refund check in your
name and your deceased spouse’s name. You can return the jointname check with Form N-110 to the Department of Taxation. A new
check will be issued in your name and mailed to you.

State your relationship to the decedent in the space provided.
Example. Your father died on August 25. You are his sole survivor.
Your father did not have a will and the court did not appoint a
personal representative for his estate. Your father is entitled to a
$300 refund. To get the refund, you must complete and attach
Form N-110 to your father’s final return. You should check the box
on line C of Form N-110, answer all the questions in Part II, and
sign your name in Part III. You must also attach a copy of the death
certificate or other proof of death. In the space provided, state that
you are the decedent’s child.

Lines 1-3
If you checked the box on line C, you must complete lines 1 through
3 in Part II.

Line B
Check the box on line B only if you are the decedent’s courtappointed personal representative claiming a refund for the
decedent on an amended individual income tax return. You must
attach a copy of the court certificate showing your appointment. If

MAILING ADDRESS
Hawaii Department of Taxation
P. O. Box 3559
Honolulu, Hawaii 96811-3559