Prescribed by the Indiana Department of Revenue Form IH-5 SF# 48834 (R2/04-07) CLAIM FOR REFUND OF INHERITANCE AND ESTATE TAXES Name of Decedent Social Security Number County of Residence Address Date of Death (if known) Inheritance Tax File Number (if known) Under Ind. Code § 6-4.1-10-1(a), the undersigned hereby makes claim for the refund of taxes paid in the aforementioned estate in the amount of ___________________________for the following reason: I hereby certify that the tax was originally paid on the ______ day of __________________, 20_______, that the ______________________ County Treasurer issued receipt number _______________, and that no part of the same has been refunded, except: PLEASE ATTACH DOCUMENTARY EVIDENCE TO SUBSTANTIATE YOUR CLAIM. Person Who Paid the Tax Name of Person Making Claim Relationship to Estate Relationship to Estate Address Address Note: Please mail completed form to: Indiana Department of Revenue, Inheritance Tax Division, 100 N. Senate Ave., Room N248, Indianapolis, Indiana 46204-2253 American LegalNet, Inc. www.FormsWorkflow.com