2016           FORM 209                                                                                                                                               Page 1
                        DELAWARE CLAIM FOR REFUND DUE
                        ON BEHALF OF DECEASED TAXPAYER

DECEDENT’SNAME                                                                    DATEOFDEATH                DECEDENT’SSOCIALSECURITYNUMBER

CLAIMANT’SNAME                                                                                               CLAIMANT’SSOCIALSECURITYNUMBER

CLAIMANT’SADDRESS

CITY                                                                        STATE  ZIPCODE

PART1. CHECKTHEBOXTHATAPPLIESTOYOU(CHECKONLYONEBOX).  MAKESURETOSIGNANDDATEINPART3BELOW

     A.          Personal representative appointedor certifiedby court. You MUST attachacourtcertificateshowingyourappointment.

     B.          Person,other than A, claiming refund for thedecedent’s estate.  CompletePart 2 and attach a copyof thedeath certificateorproofofdeath.

PART2. COMPLETETHISPARTONLYIFYOUCHECKEDBOXBABOVE
                                                                                                                                                                                                                       YES NO
     1.  Didthe decedent leavea will?..................................................................................................................................................................................

     2a. Has a personal representativebeen appointedby a court for the estate of thedecedent?..................................................................................

     2b. If “NO”, will one beappointed?................................................................................................................................................................................
               If2aor2bisanswered“YES”,thepersonalrepresentativemustfilefortherefund
     3.  As theperson claiming the refund for thedecedent’s estate,will youpayout the refund according to the
         laws of the state where the decedent was a legal resident?.................................................................................................................................
               If3isanswered“No”,arefundcannotbemadeuntilyousubmitacourtcertificate
               showingyourappointmentaspersonalrepresentativeorotherevidencethatyou
               areentitled,understatelaw,toreceivetherefund.

PART3. SIGNATUREANDVERIFICATION(ALLFILERSMUSTCOMPLETETHISPART)

I requestarefund oftaxes overpaid by or on behalf ofthe decedent. Under penalties of perjury,I declarethat I haveexamined
thisclaim, andto the best ofmyknowledgeand belief, it istrue, correct, andcomplete.

Claimant’sSignature                                                         Date

                                                                                   *DF21516019999*
         (Rev. 09/2016)                                                                                      DF21516019999