Form Or-243 - Claim To Refund Due A Deceased Person
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1Clear Form
Claim to Refund Due a Deceased Person
For office use only
Date received
00410001010000
For calendar year _________
Form OR-243
Decedent
Claimant
Name of decedent
Name of claimant
Date of death
Decedent’s Social Security number (SSN)
Claimant’s Social Security number (SSN)
Phone
Street address (permanent residence or domicile on date of death)
Street address
City
State
ZIP code
City
State
ZIP code
1. Has a personal representative for the estate been appointed by the court? ............................
Yes
No
If “Yes,” the personal representative must claim the refund.
2. Has a small-estate affidavit been filed with the county clerk? ...................................................
Yes
No
If “Yes,” the responsible party on the small-estate affidavit must claim the refund.
3. Has the probate or small estate closed? ....................................................................................
Yes
No
If “Yes,” claimant from number 6 below must claim the refund.
4. If the estate is to be probated, I am filing this statement as a (check one box only):
(a)
Personal representative of estate. (Attach a copy of court appointment.)
(b)
Responsible party filing affidavit for a small estate. (Attach a copy of the affidavit.)
For nonprobated or closed estates
5. Does the total due the decedent (except for salary or wages) from all state of Oregon
agencies exceed $10,000? .........................................................................................................
Yes
No
If “Yes,” you must file a small-estate affidavit or open a probate to receive the refund.
6. If the estate isn't to be probated or probate has closed, I qualify for payment
Revenue finance use only
under one of the following kinship groups (check one box only):
Surviving spouse or registered domestic partner.
_______________________________________________
Trustee of a revocable inter vivos trust created by the decedent.
Children of the decedent or children of a deceased child of the decedent.
_______________________________________________
Parents of the decedent.
Brothers and/or sisters of the decedent.
_______________________________________________
Nephews and/or nieces of the decedent.
Attach a photocopy of the death certificate.
If you have the original refund check, send it back with this form.
Signature and verification
I promise to use all of the money to pay the expenses of the last illness and funeral of the decedent if necessary.
If, after payment of the check by the state treasurer, the decedent’s estate is probated, I promise to account fully to the
personal representative.
If nonprobated, I promise to account fully to other persons entitled to share in this refund. I understand that the state of
Oregon isn't responsible for such accounting. I declare that there are no family members who are more closely related
to the decedent.
I declare under the penalties of false swearing that the statements herein are true.
Signature of claimant
Phone
Date
X
Return this form to: Oregon Department of Revenue
955 Center Street NE
Salem OR 97301-2555
150-101-032 (Rev. 12-16)
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