Form Rev 85 0045-1 - Affidavit Substantiating Decedent'S State Of Domicile At Death printable pdf download

Form Rev 85 0045-1 - Affidavit Substantiating Decedent'S State Of Domicile At Death

Washington State

Department of Revenue

AFFIDAVIT SUBSTANTIATING

Special Programs Division

PO Box 47477

DECEDENT’S STATE OF DOMICILE AT DEATH

Olympia, WA 98504-7477

Phone (360) 753-5547/753-7518

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

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

4. On date of death, did decedent own real property, leasehold or tangible personal property located in the

State of Washington?

Yes

5. Was decedent employed in Washington during the last five years prior to death?

Yes

6. Was decedent engaged in operating a business in Washington during the last five years prior to death?

Yes

Did decedent own any part of the business?

Yes

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

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

Please list types and which states they were issued from:

(Continued on back)

REV 85 0045-1 (06/20/05)

Form Rev 85 0045-1 - Affidavit Substantiating Decedent'S State Of Domicile At Death

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