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Form M-Nra - Massachusetts Nonresident Decedent Affidavit - Massachusetts Department Of Revenue Page 3

FORM M-NRA, PAGE 3

Name of decedent

Date of death (mm/dd/yyyy)

Social Security number

Domicile affidavit

(cont’d.)

Fill in if decedent at any time during the five years preceding death executed a will, codicil, trust indenture, deed, mortgage, lease or any other document in which

decedent was described as a a resident of Massachusetts. Describe such document and indicate what residence address(es) were given therein.

Fill in if decedent was party to any legal proceeding in Massachusetts during the five years preceding death. Indicate the tribunal, date and type of action.

Fill in if decedent belonged to any church, lodge, or other social, fraternal or religious club or organization in Massachusetts. Indicate name, address, position(s) held,

membership status, etc.

Fill in if decedent maintained a safe-deposit box or bank account(s) in Massachusetts at any time during the five years preceding death. Indicate name and address

of bank(s), and the name of any persons, other than decedent, authorized to access the box or make withdrawals.

Fill in if decedent held a Massachusetts driver’s license at any time during the five years preceding death. Indicate dates.

Fill in if an automobile was registered in decedent’s name in Massachusetts at any time during the five years preceding death. Indicate dates.

Fill in if decedent underwent medical treatment or examinations or was hospitalized in Massachusetts at any time during the five years preceding death. Indicate

name(s) and address(es) of attending physician(s) and date(s) admitted or examined.

Fill in if decedent listed Massachusetts as home or residence on any government, employment or similar form during the five years preceding death. Provide explanation.

Fill in if the question of domicile has been raised in any jurisdiction(s) for any purpose (i.e., income tax) during the five years preceding death. Indicate where and

what facts were disclosed and what decision was reached.

Indicate any other information you wish to submit in support of contention that decedent was not domiciled in Massachusetts at the time of death.