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FORM STATE OF HAWAII — DEPARTMENT OF TAXATION
N-110 Statement of Person Claiming
(REV. 2018)
Refund Due a Deceased Taxpayer
For Calendar Year
or other taxable year beginning , , 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 Number

Please Name of person claiming refund Your Social Security Number
type
or Home address (number and street). If you have a P.O. box, see instructions. Apt. No.
print
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.

A  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 previously
filed. 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 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, If you are claiming a refund on behalf of a deceased taxpayer, you
or person in a legal marital relationship shall be deemed to apply must file Form N-110 unless either of the following applies:
to partners in a civil union with the same force and effect as if they • You are a surviving spouse filing an original or amended joint
were “husband and wife,” “spouses,” or other terms that describe return with the decedent, OR
persons in a legal marital relationship.
• You are a personal representative (as discussed below) filing
Purpose of Form an original Form N-11 or N-15 for the decedent and a court
certificate showing your appointment is attached to the return.
Use Form N-110 to claim a refund on behalf of a deceased taxpayer.
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

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FORM N-110
(REV. 2018) PAGE 2

file Form N-11 for Mr. Green. You do not need to file Form N-110 you have already sent the court certificate to the Department of
to claim the refund on Mr. Green’s tax return. However, you must Taxation, complete Form N-110 and write “Certificate Previously
attach to his return a copy of the court certificate showing your Filed” at the bottom of the form.
appointment.
Line C
Personal Representative
Check the box on line C if you are not a surviving spouse claiming
For purposes of this form, a personal representative is the executor a refund based on a joint return and there is no court-appointed
or administrator of the decedent’s estate, as certified or appointed personal representative. You must also complete Part II. If you
by the court. A copy of the decedent’s will cannot be accepted as check the box on line C, you must attach the proof of death. If you
evidence that you are the personal representative. have already sent the proof of death to the Department of Taxation,
complete Form N-110 and write “Proof of Death Previously Filed”
Additional Information at the bottom of the form.
For more details, see Death of Taxpayer in the instructions for Form The proof of death must be an authentic copy of either of the
N-11 and N-15. See federal Publication 559, Survivors, Executors, following:
and Administrators, for a discussion on this matter.
• 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
P.O. Box the decedent’s death.
Enter your box number only if your post office does not deliver mail State your relationship to the decedent in the space provided.
to your home. Example. Your father died on August 25. You are his sole survivor.
Foreign Address – If your address is outside the United States or Your father did not have a will and the court did not appoint a
its possessions or territories, enter the information in the following personal representative for his estate. Your father is entitled to a
order: City, province or state, and country. Follow the country’s $300 refund. To get the refund, you must complete and attach
practice for entering the postal code. Do not abbreviate the country Form N-110 to your father’s final return. You should check the box
name. 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
Line A certificate or other proof of death. In the space provided, state that
you are the decedent’s child.
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 joint- Lines 1-3
name check with Form N-110 to the Department of Taxation. A new
check will be issued in your name and mailed to you. 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 court-
appointed 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

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