Form M-706nr - Massachusetts Nonresident Estate Tax Return And Domicile Affidavit (Page 2 of 4) in pdf

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.

Decedent’s name

Decedent’s Social Security number

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.)

I I

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.)

I I

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.)

I I

17 Did the decedent ever live in Massachusetts?

Yes

No. If yes, during what period(s)?

_________________________________________________________________________________________________________________________

18 Indicate the address, nature of decedent’s places of residence (e.g., house rented or owned, apartment, hotel or home of relatives or friends) and

lengths of periods outside Massachusetts during the five years preceding death.

_________________________________________________________________________________________________________________________

19 Indicate the address, nature of decedent's places of residence and lengths of periods in Massachusetts during the five years preceding death.

_________________________________________________________________________________________________________________________

10 Where and in what years did the decedent vote or register to vote during the five years preceding death?

_________________________________________________________________________________________________________________________

11 To what state, county or municipality and in what years did the decedent pay a tax on income, real estate, or on intangible property during the last

five years?

_________________________________________________________________________________________________________________________

12 For which taxable year did the decedent last file a Massachusetts income tax return? ________________________________________________

13 In what office(s) of the Internal Revenue Service did the decedent file his federal income tax returns during the five years preceding death? What

was stated therein to be the decedent’s residence?

_________________________________________________________________________________________________________________________

Form M-706nr - Massachusetts Nonresident Estate Tax Return And Domicile Affidavit Page 2

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