Wisconsin Claim for Decedent's Wisconsin Income Tax Refund

Claim for Decedent's Wisconsin Income Tax Refund
2023 I-804 Form 804 Claim for Decedent's Wisconsin Income Tax Refund (fillable)
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Claim for Decedent’s
Wisconsin Income Tax Refund

804

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Wisconsin Department
of Revenue

See instructions on back.

Tax year decedent was due a refund:
Calendar year	

, or other tax year beginning	

Please print or type

, 20	

, and ending	

, 20

Use BLACK ink

Decedent’s legal last name

Decedent’s legal first name

M.I.

Decedent’s social security number

Your legal last name (name of person claiming refund)

Legal first name

M.I.

Your social security number

Your address (number and street)

City or post office. If you have a foreign address, see instructions.

	 Part I	

Apt. No.

State

Date of decedent’s death

Zip code

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

Relationship to decedent:
Court-appointed or certified personal representative. Attach a domiciliary letter showing your appointment,
unless previously filed (see instructions).
Claims will be given preference to relatives in the following order:
1. Surviving spouse
2. Child
3. Parent
4. Brother or sister
5. Creditor of decedent

	Part II	 Signature and verification.
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.
Signature of Person Claiming Refund

Mail this form to:
Wisconsin Department of Revenue
PO Box 8903
Madison WI 53708-8903

I-804 (R. 9-21)

Date

Page 2

Form 804

General Instructions
Purpose of Form
Use Form 804 to claim a refund on behalf of a decedent (deceased taxpayer).
Where To File
If you are filing the decedent’s income tax return, submit Form 804 with the return. Also, check the box below the special conditions
box on page 1 of Form 1 or 1NPR indicating you are filing Form 804 with the return.
If filing a paper return, place Form 804 on top of Form 1 or Form 1NPR. If filing electronically, attach Form 804 as a PDF to the return.
If the refund check was issued in the decedent’s name, and you are unable to cash the check, send Form 804 along with the decedent’s refund check to:	
	
	
	

Wisconsin Department of Revenue	
PO Box 8903
Madison WI 53708-8903

Personal Representative
For purposes of this form, a personal representative is the executor or administrator of the decedent’s estate, as appointed or certified
by the court. You must submit your domiciliary letter showing your appointment. A copy of the decedent’s will or Transfer by Affidavit
cannot be accepted as evidence that you are the personal representative.

Specific Instructions
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.
Court Appointed or Certified Personal Representative
Check the box only if you are the decedent’s court-appointed personal representative claiming a refund for the decedent. You must
attach a copy of the domiciliary letter showing your appointment.
Lines 1 through 5
If you are not a court appointed or certified personal representative, check one of the boxes on lines 1 through 5 which indicates your
relationship to the decedent. If you check any of the boxes on lines 1 through 5, you must have proof of death. The proof of death is
either of the following:
•	 The original death certificate
•	 The formal notification from the appropriate government office (for example, Department of Defense) informing the next of kin of
the decedent’s death
Note: Do not attach the original death certificate or other proof of death to Form 804. Instead, keep it for your records and provide
it if requested.
Line 1
Check the box on line 1 if you are a surviving spouse of the decedent and there is no court appointed personal representative.
Line 2
Check the box on line 2 if you are a surviving child of the decedent and there is no court appointed personal representative.
Line 3
Check the box on line 3 if you are the surviving parent of the decedent.
Line 4
Check the box on line 4 if you are the surviving brother or sister of the decedent.
Line 5
Check the box on line 5 if you are a creditor of the decedent.
Applicable Laws and Rules
This document provides statements or interpretations of the following laws and regulations enacted as of September 6, 2023:
Chapter 71, Wis. Stats.