Office of the Illinois State Treasurer
PETITION FOR ESTATE TAX REFUND
This form must be notarized and mailed to the following address:
Illinois State Treasurer's Office
Attn: Estate Tax Section
400 W. Monroe St. - 4th Fl.
Springfield, IL 62704-1800
For assistance completing this form, please call (800) 252-8919
In case our Office has questions on this completed form, please provide a contact name, phone number and email address:
Contact Name__________________________ Number___________________ Email_______________________________
DECEDENT NAME: _______________________________________ DECEDENT SSN: __________________________
DATE OF DEATH: _____________________ COUNTY OF ASSESSMENT: ___________________________
Total amount of Tax, Interest and Penalties Assessed on the Estate by the Attorney General's Office:
$________________________
enclose copies of all Attorney General Certificate(s) of Discharge and Determination of Tax
Attorney General's Estate Tax File No:__________________________ found on AG Certificate of Discharge
Total Payment(s) Made on Behalf of Estate: $____________________ enclose copies of all payment receipt(s)
Amount of Refund Requested: $_____________________________
MAKE REFUND PAYABLE TO:
(Example: Estate of John Doe)
(not to exceed 30 characters)
Attention or Address Line 1:
(not to exceed 30 characters)
Address Line 2: (not to exceed 30 characters)
City:_________________________________ State:_____________ Zip:______________
Signature of duly appointed Estate Representative Title/Authority of duly appointed Estate Representative
(For example, Administrator, Executor, Trustee, etc.)
State of ____________________
County of __________________________
Signed and sworn (or affirmed) to before me on ______________________ (date) by
_________________________________________(name of duly appointed Estate Representative).
(Signature of Notary Public)
(Seal)
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