Vermont Department of Taxes
133 State Street                                                                                     Phone:  (802) 828-6820
Montpelier, VT  05601-0547

                                    STATEMENT OF CLAIMANT TO REFUND DUE                                      Form
Vermont
                                    ON BEHALF OF DECEASED TAXPAYER                                           176

           Decedent’s Name               Social Security Number

           Address at Time of Death      Date of Death

  DECEDENT City                          State                                                       ZIP Code

           Claimant’s Name               Social Security Number

           Address                       Relationship or other capacity

  CLAIMANT City                          State                                                       ZIP Code

A.  Has an executor or administrator been appointed for the estate of the above-named decedent?
             Yes*.  
             No.  Will an executor or administrator be appointed for the estate? ................   Yes*      No
* If you answered “Yes” to either of these questions, the executor or administrator must file for the refund.

B.  Did the decedent have, at the time of his/her death, any interest in real estate, stocks, bonds, 
  joint bank accounts or property, trusts, partnerships, or through power of appointment, either 
  as joint beneficiary, joint tenant, or tenant by the entirety with right of survivorship?
             Yes.  What was the total value of those assets at time of death? ............. $_______________________
             No.

SIGNATURE OF CLAIMANT
I request a refund of taxes overpaid by or on behalf of the decedent.  Under penalties of perjury, I declare that I have 
examined this claim, and to the best of my knowledge and belief, it is true, correct, and complete.
                                    Date                                                             Daytime Telephone Number
           SIGN
           HERE

                                                                                                             Form  176
                                                                                                              Rev. 04/12