Fillable Printable Affidavit Substantiating Decedent's State of Domicile at Death - Washington
Fillable Printable Affidavit Substantiating Decedent's State of Domicile at Death - Washington
Affidavit Substantiating Decedent's State of Domicile at Death - Washington
AFFIDAVIT SUBSTANTIATING
DECEDENT’S STATE OF DOMICILE AT DEATH
The following affidavit will be used by the Washington State Department of Revenue to help determine the state of
residency of a decedent when the state of domicile is in dispute. This affidavit should be sworn to by a person having
personal knowledge of the facts (i.e., surviving spouse, member of immediate family, personal representative, etc.).
Name of Decedent
First Middle Last
Date of Death / /
1. Where was the decedent’s primary residence at the date of death? (city, state, country)
What was decedent’s mailing address at the date of death?
Street Address
City State Zip Code
How long at this location? To the best of your knowledge, what state did the decedent intend to reside
in until the date of his/her death?
2. Did decedent reside in a nursing home in Washington at date of death?
Yes No
Length of stay
Circumstances warranting stay
3. Did decedent own a home(s)?
Yes No. If yes, give city and state:
Is the home currently being rented or leased?
Yes No Is the home available for rent or lease? Yes No
4. On date of death, did decedent own real property, leasehold or tangible personal property located in the
State of Washington?
Yes No
5. Was decedent employed in Washington during the last five years prior to death?
Yes No
6. Was decedent engaged in operating a business in Washington during the last five years prior to death?
Yes No
Did decedent own any part of the business?
Yes No
Please further describe decedent’s participation:
________________________________________________________________________________________
7. Decedent’s last federal income tax return prior to death was filed with which IRS Service Center?
_______________________________________ On what date? ______/______/______
City State
Address shown on return
Street Address City State Zip Code
8. Did decedent own or lease a motor vehicle(s)? Yes No
If yes, in what states were they registered?
9. Was decedent registered to vote?
Yes No If yes, in what state was he/she registered?
10. Did the decedent hold a driver’s license at date of death?
Yes No For what state?
11. Did decedent hold any other types of licenses or permits at date of death?
Yes No
Please list types and which states they were issued from:
(Continued on back)
REV 85 0045 (6/26/14)
State of Washington
Department of Revenue
Special Programs Division
Miscellaneous Tax
PO Box 47477
Olympia WA 98504-7477
12. Did decedent hold membership in any community or religious organizations, clubs or societies in Washington within the
last five years?
Yes No If yes, please list:
13. Did decedent rent any safe deposit boxes in Washington at date of death? Yes No
14. Did decedent visit Washington within five years prior to the date of death?
Yes No If yes, please list location,
date and reason for each visit:
Location Date Reason
15. Did the decedent declare a state of residence near the date of death? Yes No
Which state?
To whom was this declaration made?
First Last
What was the approximate date of the declaration? ______/______/_____
16. If out-of-state domicile is claimed, state any additional facts relied upon to support this claim.
I, the undersigned, reside at
My relationship to the decedent is
. The above information is submitted under
penalty of perjury in support of the statement that the above decedent was domiciled in the State
of ,
city of
, at the date of death.
Affidavit Preparer: X Date _______/_______/_______
State of , County of
I certify that I know or have satisfactory evidence that
(name of person)
is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged
it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument
Dated: / /
Signature of Notary Public
(SEAL OR STAMP)
Residing at:
Notary Public in and for the State of
My appointment expires: _______/________
For tax assistance call (360) 534-1503, option 2. To request this document in an alternate format, please call 1-800-647-7706. Teletype
(TTY) users may use the Washington Relay Service by calling 711.
REV 85 0045 (6/26/14)
