Fillable Printable Massachusetts Nonresident Decedent Affidavit

Massachusetts Nonresident Decedent Affidavit

Form M-NRA

Massachusetts Nonresident

Decedent Affidavit

Rev. 12/02

Massachusetts

Department of

Revenue

To be used only for estates of nonresidents with dates of death on or after January 1, 2003.

Decedent’s first name and middle initial Last name Date of death Social Security number

Street address of residence or domicile at time of death City/Town State Zip

Probate court Docket number

Name of executor(s) (see instructions) Designation

Street address City/Town State Zip

Name of attorney(s) representing the estate (if any) Telephone

Street address City/Town State Zip

Domicile Affidavit

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) __________________________________________________

__________________________________________________________________________________________________________________________________

b Year domicile established______________________________________________________________________________________________

12aPlace of decedent’s death _____________________________________________________________________________________________

(Attach copy of death certificate) Home, hospital, etc. City/Town State

b Place of burial ______________________________________________________________________________________________________

c Residence address at death ____________________________________________________________________________________________

___________________________________________________________________________________________________________________

d Date and place of birth________________________________________________________________________________________________

13 What is your relationship to decedent? _____________________________________________________________________________________

14 What 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.)

15 Did 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.)

16 If 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.)

❿ ❿❿

17 Did the decedent ever live in Massachusetts? ■■ Yes ■■ No. If yes, during what period(s)?

_________________________________________________________________________________________________________________________

18 Indicate 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.

_________________________________________________________________________________________________________________________

19 Indicate the address, nature of decedent's places of residence and lengths of periods in Massachusetts during the five years preceding death.

_________________________________________________________________________________________________________________________

10 Where and in what years did the decedent vote or register to vote during the five years preceding death?

_________________________________________________________________________________________________________________________

11 To 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

five years?

_________________________________________________________________________________________________________________________

12 For which taxable year did the decedent last file a Massachusetts income tax return? ________________________________________________

13 In 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?

_________________________________________________________________________________________________________________________

14 What 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.

_________________________________________________________________________________________________________________________

15 Did 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

application.

_________________________________________________________________________________________________________________________

16 Did 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.

_________________________________________________________________________________________________________________________

17 Was 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?

_________________________________________________________________________________________________________________________

18 Did 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.

_________________________________________________________________________________________________________________________

19 Did 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?

_________________________________________________________________________________________________________________________

20 Did the decedent hold a Massachusetts driver’s license at any time during the five years preceding death? ■■ Yes ■■ No. If yes, give dates.

_________________________________________________________________________________________________________________________

21 Was an automobile registered in the decedent’s name in Massachusetts at any time within five years preceding death? ■■ Yes ■■ No. If yes, give dates.

_________________________________________________________________________________________________________________________

22 Did 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.

_________________________________________________________________________________________________________________________

23 Did 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.

_________________________________________________________________________________________________________________________

24 Has 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.

_________________________________________________________________________________________________________________________

25 What other information do you desire to submit in support of the contention that the decedent was not domiciled in Massachusetts at the time of

death?

_________________________________________________________________________________________________________________________

26 Complete 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.

Item Description U.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

and complete.

Signature of surviving spouse, etc., having personal knowledge of the foregoing Date

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 MA 02204.