Form Rev-1737-1 Ex - Nonresident Decedent Affidavit Of Domicile

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REV-1737-1 EX + (6-08)

NONRESIDENT DECEDENT

AFFIDAVIT OF DOMICILE

PO BOX 280601

HARRISBURG, PA 17128-0601

This affidavit must be completed and sworn to by a person having personal knowledge of these

facts, preferably by a surviving spouse or member of the decedent’s family.

START

Name of Decedent

Date of Death

MM/DD/YYYY

Legal Address at Time of Death:

Street Address

City/Borough

State

ZIP Code

The following information is submitted in support of the statement that the above individual was

not domiciled in the Commonwealth of Pennsylvania at the date of death.

Names and addresses of the decedent’s surviving spouse and members of his/her immediate family:

Name and Relationship to Decedent

Street Address

City/Borough

State

ZIP Code

Name and Relationship to Decedent

Street Address

City/Borough

State

ZIP Code

Name and Relationship to Decedent

Street Address

City/Borough

State

ZIP Code

Did the decedent ever live in Pennsylvania?

Yes

If yes, during what periods?

Did the decedent spend time in Pennsylvania during the five years preceding death ?

Yes

If yes, during what periods and at what address(es)?

What was the nature of decedent’s place(s) of residence during the five years immediately preceding death?

Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, and/or whether decedent resided in a

hotel or the home of relatives or friends.

Was the decedent employed during the five years preceding death?

Yes

If yes, list the name(s) and address(es) of employer(s).

Did the decedent leave a will?

Yes

If yes, state the court that admitted the will to probate and the date admitted, and attach a copy (including all codicils) and a certificate of issuance of

letters testamentary.

If the decedent did not leave a will, has an administrator of the estate been appointed?

Yes

If yes, state the court that appointed the administrator and the date of appointment, and attach a certificate of the issuance of letters of administration.

8. At any time during the last five years did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease or any other document in which

the decedent was described as a resident of Pennsylvania?

Yes

If yes, describe such document.

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