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Form M-Nra - Massachusetts Nonresident Decedent Affidavit - Massachusetts Department Of Revenue

Massachusetts Department of Revenue

Form M-NRA

Massachusetts Nonresident Decedent Affidavit

Name of decedent

Date of death (mm/dd/yyyy)

Social Security number

Street address

City/Town

State

Zip

County of probate court

Case/Docket number

Name of executor/personal representative

Designation

Street address

City/Town

State

Zip

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

Phone

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 nonresident 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 execu-

tor/personal representative 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 signator of this document, 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.

01a

City/town and state or country where decedent was domiciled at date of death

Year domicile established

02a

Place of decedent’s death (attach copy of death certificate): Home, hospital, etc.

City/town and state or country

02b

Place of burial

Date and place of birth

Your relationship to decedent

List names and residence addresses of decedent’s surviving spouse and members of immediate family, including children and parents. If none, list brothers and sisters.

Attach separate listing if needed.

Declaration

I declare under the pains and penalty of perjury that to the best of my knowledge, the information contained herein is accurate and complete.

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

Date

Signature of executor/personal representative or administrator (or person with actual or constructive possession of the property)

Date

Mail to: Massachusetts Department of Revenue, PO Box 7023, Boston MA 02204.

Rev. 6/16