![]() Enlarge image | 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 |