Form M-Nra - Massachusetts Nonresident Decedent Affidavit

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Rev. 12/02
Form M-NRA
Massachusetts
Massachusetts Nonresident
Department of
Decedent Affidavit
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:
11 a Place where decedent was domiciled at date of death (city and state or country) __________________________________________________
__________________________________________________________________________________________________________________________________
b Year domicile established______________________________________________________________________________________________
12 a Place 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.)
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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.)
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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.)

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