Fillable Printable Massachusetts Nonresident Decedent Affidavit
Fillable Printable Massachusetts Nonresident Decedent Affidavit
Massachusetts Nonresident Decedent Affidavit
To be used only for estates of nonresidents with dates of death on or after January 1, 2003.
Decedent’s first name and middle initialLast nameDate of deathSocial Security number
Street address of residence or domicile at time of deathCity/TownStateZip
Probate courtDocket number
Name of executor(s) (see instructions)Designation
Name of attorney(s) representing the estate (if any)Telephone
This affidavit must be submitted in nonresident cases. It must be completed and sworn to by the surviving spouse or member of the immediate family
of the decedent having personal knowledge of the facts; or, if such spouse or member of the immediate family does not possess such knowledge, then
it must be submitted by some person having such personal knowledge. The affidavit must also be sworn to and signed by the executor, administrator
or person having actual or constructive possession of the property, if any.
Every question must be answered. Write “not applicable” or “none,” if necessary. Use additional pages if necessary.
The undersigned, ________________________________________________________ , under penalty of perjury, makes the following statements,
based on personal knowledge of the facts set forth herein, for the purpose of establishing the place of decedent’s domicile at the date of death:
11aPlace where decedent was domiciled at date of death (city and state or country)__________________________________________________
bYear domicile established______________________________________________________________________________________________
12aPlace of decedent’s death_____________________________________________________________________________________________
(Attach copy of death certificate)Home, hospital, etc.City/TownState
bPlace of burial______________________________________________________________________________________________________
cResidence address at death____________________________________________________________________________________________
dDate and place of birth________________________________________________________________________________________________
13What is your relationship to decedent?_____________________________________________________________________________________
14What are the names and residence addresses of decedent’s surviving spouse and members of the immediate family including children and
parents? If none of the above, list brothers and sisters.
(Attach separate listing if necessary.)
15Did the decedent leave a will?■■Yes■■No.If yes, name the court(s) which admitted the will to probate, the docket number, the date admitted
and also the court(s) which allowed ancillary administration.
(Attach an attested copy of the will and petition for probate of will listing the heirs at law unless filed previously.)
16If the decedent did not leave a will, has an administrator of the estate been appointed?■■Yes■■No.If yes, name each court which appointed an
administrator or ancillary administrator and indicate the date of appointment for each.
(Attach an attested copy of the petition for administration listing the heirs at law unless filed previously.)
17Did the decedent ever live in Massachusetts?■■Yes■■No.If yes, during what period(s)?
18Indicate the address, nature of decedent’s places of residence (e.g., house rented or owned, apartment, hotel or home of relatives or friends) and
lengths of periods outside Massachusetts during the five years preceding death.
19Indicate the address, nature of decedent's places of residence and lengths of periods in Massachusetts during the five years preceding death.
10Where and in what years did the decedent vote or register to vote during the five years preceding death?
11To what state, county or municipality and in what years did the decedent pay a tax on income, real estate, or on intangible property during the last
12For which taxable year did the decedent last file a Massachusetts income tax return?________________________________________________
13In what office(s) of the Internal Revenue Service did the decedent file his federal income tax returns during the five years preceding death? What
was stated therein to be the decedent’s residence?
14What was the decedent’s occupation in the five years preceding death?___________________________________________________________
Give name and address of employer. If self-employed, indicate same; if in partnership, give the name and address of the firm and the individual
partners. If decedent owned a business, give details.
15Did the decedent make application for a passport within the last five years?■■Yes■■No.If yes, give date(s) and place(s) and home address on
16Did the decedent at any time during the five years preceding death execute a will, codicil, trust indenture, deed, mortgage, lease or any other
document in which decedent was described as a resident of Massachusetts?■■Yes■■No.If yes, describe such document and state what
residence address(es) were set forth therein.
17Was the decedent a party to any legal proceeding in Massachusetts during the last five years?■■Yes■■No.If yes, what was the tribunal, date
and type of action?
18Did decedent belong to any church, lodge, or other social, fraternal or religious club or organization in Massachusetts?■■Yes■■No.If yes, give
name, address, positions held, membership status, etc.
19Did the decedent maintain a safe-deposit box or bank accounts in Massachusetts at any time during the five years preceding death?
■■Yes■■No.If yes, give name and address of bank(s). Who, other than the decedent, was authorized to open the box or make withdrawals?
20Did the decedent hold a Massachusetts driver’s license at any time during the five years preceding death?■■Yes■■No.If yes, give dates.
21Was an automobile registered in the decedent’s name in Massachusetts at any time within five years preceding death?■■Yes■■No.If yes, give dates.
22Did the decedent undergo medical treatment or examinations, or was the decedent hospitalized in Massachusetts at any time within five years
preceding death?■■Yes■■No.If yes, please furnish names and addresses of the attending physicians and dates admitted or examined.
23Did the decedent within five years prior to death indicate Massachusetts as home or residence on any government, employment, or similar
form?■■Yes■■No.If yes, provide explanation.
24Has question of domicile been raised in any jurisdictions for any purpose, i.e. income tax, in the last five years?■■Yes■■No.If yes, state where,
what facts were disclosed and what decision was reached.
25What other information do you desire to submit in support of the contention that the decedent was not domiciled in Massachusetts at the time of
26Complete the schedule below, listing gross values of all real and/or tangible personal property having an actual situs in Massachusetts includible
in the gross estate. Indicate reference(s) the July 1999 revision of to U.S. Form 706. Do not deduct the value of any mortgage or lien.
ItemDescriptionU.S. schedule & line no.Gross value
Total gross value. Enter the total gross value here and in Form M-706, Part 3, line 3 or Form M-4422, Part 3, line 3. . .
If more space is needed, attach additional sheets of the same size.
Under the penalties of perjury, I declare this affidavit has been examined by me and is, to the best of my knowledge and belief, true, correct
Signature of surviving spouse, etc., having personal knowledge of the foregoingDate
Signature of executor or administrator (or person with actual or constructive possession)Date
Mail to: Massachusetts Department of Revenue, Bureau of Desk Audit, Estate Tax Unit, PO Box 7023, Boston MA02204.