Free November 2005 I-804 Claim for Decedent's Wisconsin Income Tax Refund - Wisconsin

State of Wisconsin

DEPARTMENT OF REVENUE
2135 RIMROCK ROAD MADISON, WI www.dor.state.wi.us ADDRESS MAIL TO: TAX PROCESSING BUREAU MAIL STOP 3-138 PO BOX 8903 MADISON, WI 53708-8903

TAXPAYER SERVICES DIVISION

CLAIM FOR DECEDENT'S WISCONSIN INCOME TAX REFUND

The information requested below is necessary to enable us to issue the refund claimed on a deceased person's tax return. 1. Decedent's full name a. Date of death 2. What proceedings have been or will be begun in the name of the decedent?
Formal or Informal Probate Summary Settlement or Summary Assignment Survivorship Marital Property Termination of Joint Tenancy Transfer by Affidavit None

SS#

3. If proceedings are "Formal or Informal Probate" the refund will be issued to the personal representative.
a. Personal Representative's Name

b. Personal Representative's Address

4. If proceedings are NOT "Formal or Informal Probate", provide the following:
a. Claimant's Name b. Claimant's Social Security Number

c. Claimant's Address

d. Claimant's Relationship to the Decedent

e. Living Relative(s) to the Decedent Other Than the Claimant Widow or Widower Brother or Sister Parents Children None

The claimant named below requests the refund of income taxes overpaid by or on the behalf of the deceased to the State of Wisconsin for the year in the amount of $ . I hereby declare that the information provided herein is true and correct to the best of my knowledge and belief.

Claimant's Signature

Date

I-804 (R. 11-05)