Massachusetts Nonresident Decedent Affidavit Free Download

Form M-NRA

Massachusetts Nonresident

Decedent Affidavit

Rev. 12/02

Massachusetts

Department of

Revenue

To be used only for estates of nonresidents with dates of death on or after January 1, 2003.

Decedent’s first name and middle initial Last name Date of death Social Security number

Street address of residence or domicile at time of death City/Town State Zip

Probate court Docket number

Name of executor(s) (see instructions) Designation

Street address City/Town State Zip

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

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 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. Use additional pages if necessary.

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:

11aPlace where decedent was domiciled at date of death (city and state or country) __________________________________________________

__________________________________________________________________________________________________________________________________

b Year domicile established______________________________________________________________________________________________

12aPlace 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.)

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.)

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.)

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Massachusetts Nonresident Decedent Affidavit