Pennsylvania Application For Refund/Rebate Due the Decedent

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Application For Refund/Rebate Due the Decedent
Application for Property Tax/Rent Rebate Due the Decedent (DEX-41)DEX-41

(EX) 04-22 (FI)

BUREAU OF INDIVIDUAL TAXES
PO BOX 280508
HARRISBURG PA 17128-0508

SECTION I

APPLICATION FOR
PROPERTY TAX/RENT
REBATE DUE THE DECEDENT

DECEDENT INFORMATION

START Name of Decedent

Date of Death

➜

SECTION II

Decedent’s Social Security Number

APPLICATION SUBMITTER INFORMATION

Name
Street Address
City

State

ZIP Code

I am filing this application as (select only one oval):
1.

The surviving spouse. (Attach a copy of the decedent’s death certificate.)

The personal representative of the decedent’s estate. (Attach a copy of a short certificate or court order showing your appointment.)

The personal representative of the decedent where a will has NOT been probated or where there is no will. (Attach a copy of the
decedent’s death certificate and a receipted copy of the claimant’s funeral bill and proof that you directly paid for funeral expenses that
are equal to or greater than the amount of the rebate being claimed. Acceptable proof of this payment include the front and back of the
canceled check, a credit card/bank statement, or other document showing you personally paid for the funeral expenses.
State your relationship to the decedent:
. Sign the affidavit below and have your signature notarized.)

SECTION III

AFFIDAVIT

Complete Section III only if Oval 3 is selected in Section II.
I am making a request for monies due the decedent and certify that the information provided on this claim has been examined by me and is,
to the best of my knowledge, true and correct. Any monies that I receive as a result of this claim will be disbursed according to the laws of
the Commonwealth of Pennsylvania.

PLEASE SIGN AFTER PRINTING
(SIGNATURE OF PERSON FILING THIS CLAIM)

SECTION IV

NOTARIZATION

Subscribed and sworn before me this

day of

PLEASE SIGN AFTER PRINTING
(SIGNATURE OF NOTARY PUBLIC)

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Extracted from PDF file 2023-pennsylvania-form-dex-41.pdf, last modified June 2018

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More about the Pennsylvania Form DEX-41 Other TY 2023

We last updated the Application For Refund/Rebate Due the Decedent in January 2024, so this is the latest version of Form DEX-41, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form DEX-41 directly from TaxFormFinder. You can print other Pennsylvania tax forms here.

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Other Pennsylvania Other Forms:

TaxFormFinder has an additional 174 Pennsylvania income tax forms that you may need, plus all federal income tax forms.

Form Code	Form Name
Form PA-1000	Property Tax or Rent Rebate Claim
Form PA-1000 Booklet	Property Tax or Rent Rebate Program Instruction Booklet Tax Credit
Form PA-1000 RC	PA Rent Certificate - PA Rent Certificate and Rental Occupancy Affidavit (PA Property Tax/Rent Rebate)
Form REV-1176	E-TIDES Administrative Access Change Request Form
Form REV-181	Application for a PA Tax Clearance Certificate

Download all PA tax forms View all 175 Pennsylvania Income Tax Forms

Form Sources:

Pennsylvania usually releases forms for the current tax year between January and April. We last updated Pennsylvania Form DEX-41 from the Department of Revenue in January 2024.

Show Sources >

Historical Past-Year Versions of Pennsylvania Form DEX-41

We have a total of three past-year versions of Form DEX-41 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:

2023 Form DEX-41

Application for Property Tax/Rent Rebate Due the Decedent (DEX-41)

2022 Form DEX-41

Application for Property Tax/Rent Rebate Due the Decedent (DEX-41)

2021 Form DEX-41

Application For Refund/Rebate Due the Decedent (DEX-41)

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