R-6642 (1/16) 
                                                                                      Mail to: 
                                                                                      Louisiana Department of Revenue
                                          Statement of Claimant to Refund Due on      P.O. Box 4998
                                          Behalf of Deceased Taxpayer                 Baton Rouge, La 70821-4998
                                                                                      Phone: 855.307.3893
                                                                                      Fax: 225.219.6220

 Date Statement is Executed

 Name of Deceased Taxpayer                Taxpayer’s Social Security Number

I, _________________________________________________ hereby certify that I am the ______________________________ of the
                           (Please Print)                                             (Relationship or other capacity)
deceased taxpayer and hereby make request for refund of the income taxes overpaid by or in behalf of the decedent.

Note: A certificate of death must accompany this document.
 I, the undersigned claimant, certify, under all penalties, fines, and forfeitures imposed by law for the making of false or fraudulent 
 claims against the State of Louisiana or the making of false statements in connection therewith, declare that if said refund is issued to 
 him/her, he/she will see that the proceeds thereof are disposed of according to law. 
 Signature of Claimant                    Claimant’s Social Security Number

 Address of Claimant

 City                                                                                 State    ZIP