Affidavit Substantiating Decedent'S State Of Domicile At Death - Washington State Department Of Revenue Page 2

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12. Did decedent hold membership in any community or religious organizations, clubs or societies in Washington within the
last five years?
Yes
No
If yes, please list:
13. Did decedent rent any safe deposit boxes in Washington at date of death?
Yes
No
14. Did decedent visit Washington within five years prior to the date of death?
Yes
No If yes, please list location,
date and reason for each visit:
Location
Date
Reason
15. Did the decedent declare a state of residence near the date of death?
Yes
No
Which state?
To whom was this declaration made?
First
Last
What was the approximate date of the declaration? ______/______/_____
16. If out-of-state domicile is claimed, state any additional facts relied upon to support this claim.
I, the undersigned, reside at
My relationship to the decedent is
. The above information is submitted under
penalty of perjury in support of the statement that the above decedent was domiciled in the State of
,
city of
, at the date of death.
Affidavit Preparer: X
Date _______/_______/_______
State of
, County of
I certify that I know or have satisfactory evidence that
(name of person)
is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged
it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument
Dated:
/
/
Signature of Notary Public
(SEAL OR STAMP)
Residing at:
Notary Public in and for the State of
My appointment expires: _______/________
For tax assistance, visit dor.wa.gov or call 1-800-647-7706. To inquire about the availability of this document in an alternate format for
the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
REV 85 0045 (11/18/09)

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