Clear FormFORM

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		

Date of death

Decedent’s Social Security NumberYour Social Security Number
Please Name of person claiming refund			
type
Home address (number and street). If you have a P.O. box, see instructions.			 Apt. No.
orprint
City, town, or post office, state and Postal/ZIP code. If you have a foreign address, see instructions.

Part I

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

 Surviving spouse requesting reissuance of a refund check. See instructions.
B  Court-appointed or certified personal representative. Attach a court certificate showing your appointment, unless previouslyAfiled. See instructions.
C Person, other than A or B, claiming refund for the decedent’s estate. Also, complete Part II. Attach a copy of the proof ofdeath, 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 NO1
2

Did the decedent leave a will?...............................................................................................................................................
(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 lawsof 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 aspersonal 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 section231-36, 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 		

DateGeneral Instructions

Who Must FileNOTE: 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, youmust 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) filingan 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 histax return. On April 3 of the same year, you were appointed by thecourt 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 yourappointment.

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 asevidence that you are the personal representative.

Additional Information

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

Line C
Check the box on line C if you are not a surviving spouse claiminga 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 thefollowing:•The death certificate, orSpecific 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. BoxEnter your box number only if your post office does not deliver mailto 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 yourname and your deceased spouse’s name. You can return the jointname check with Form N-110 to the Department of Taxation. A newcheck 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, andsign your name in Part III. You must also attach a copy of the deathcertificate or other proof of death. In the space provided, state thatyou are the decedent’s child.

Lines 1-3
If you checked the box on line C, you must complete lines 1 through3 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 thedecedent on an amended individual income tax return. You must
attach a copy of the court certificate showing your appointment. IfMAILING ADDRESS
Hawaii Department of Taxation
P. O. Box 3559
Honolulu, Hawaii 96811-3559