West Virginia Statement of Claimant to Refund Due Deceased Taxpayer

Statement of Claimant to Refund Due Deceased Taxpayer
Form IT140 Schedule F
2023

Schedule
STATEMENT OF CLAIMANT
F
Form IT-140 B
TO REFUND DUE DECEASED TAXPAYER
Attach completed schedule to decedent’s return
NAME OF
DECEDENT
DATE OF
DEATH

NAME OF
CLAIMANT
SOCIAL SECURITY
NUMBER

SOCIAL SECURITY
NUMBER

ADDRESS
(permanent residence or
domicile at date of death)
CITY

ADDRESS

STATE

ZIP
CODE

CITY

ZIP
CODE

STATE

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

Surviving wife or husband, claiming a refund based on a joint return

B.

Administrator or executor. Attach a court certificate showing your appointment.

C.

Claimant for the estate of the decedent, other than above. Complete the rest of this schedule and attach
a copy of the death certificate or proof of death*

ATTACH A LIST TO THIS SCHEDULE CONTAINING THE NAME
AND ADDRESS OF THE SURVIVING SPOUSE AND CHILDREN OF
THE DECEDENT.

TO BE COMPLETED ONLY IF BOX C ABOVE IS CHECKED
YES NO
1.

Did the decedent leave a will?....................................................................................................................................................................

2(a).Has an administrator or executor been appointed for the estate of the decedent?......................................................................................
2(b) If "NO" will one be appointed?......................................................................................................................................................................
If 2(a) or 2(b) is checked "YES", do not file this form. The administrator or executor should file for the refund.
3.

Will you, as the claimant for the estate of the decedent, disburse the refund according to the laws of the state in which the decedent
was domiciled or maintained a permanent residence?.................................................................................................................................
If "NO", payment of this claim will be withheld pending submission of proof of your appointment as administrator or executor or other evidence showing that you are authorized under state law to receive payment.

SIGNATURE AND VERIFICATION

I hereby make request for refund of taxes overpaid by, or on behalf of the decedent and declare under penalties of perjury, 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 _______________________________
*May be the original of an authentic copy of a telegram or letter from the Division of Defense notifying the next of kin of death while in
active service, or a death certificate issued by the appropriate officer of the Division of Defense.

*P40202313A*
P

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