Massachusetts Nonresident Decedent Affidavit

19 Did the decedent maintain a safe-deposit box or bank accounts in Massachusetts at any time during the five years preceding death?
Yes No. If yes, give name and address of bank(s). Who, other than the decedent, was authorized to open the box or make withdrawals?
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20 Did the decedent hold a Massachusetts drivers license at any time during the five years preceding death? Yes No. If yes, give dates.
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21 Was an automobile registered in the decedent’s name in Massachusetts at any time within five years preceding death? Yes No. If yes, give dates.
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22 Did the decedent undergo medical treatment or examinations, or was the decedent hospitalized in Massachusetts at any time within five years
preceding death? Yes No. If yes, please furnish names and addresses of the attending physicians and dates admitted or examined.
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23 Did the decedent within five years prior to death indicate Massachusetts as home or residence on any government, employment, or similar
form? Yes No. If yes, provide explanation.
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24 Has question of domicile been raised in any jurisdictions for any purpose, i.e. income tax, in the last five years? Yes No. If yes, state where,
what facts were disclosed and what decision was reached.
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25 What other information do you desire to submit in support of the contention that the decedent was not domiciled in Massachusetts at the time of
death?
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26 Complete the schedule below, listing gross values of all real and/or tangible personal property having an actual situs in Massachusetts includible
in the gross estate. Indicate reference(s) the July 1999 revision of to U.S. Form 706. Do not deduct the value of any mortgage or lien.
Item Description U.S. schedule & line no. Gross value
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Total gross value. Enter the total gross value here and in Form M-706, Part 3, line 3 or Form M-4422, Part 3, line 3. . .
If more space is needed, attach additional sheets of the same size.
Under the penalties of perjury, I declare this affidavit has been examined by me and is, to the best of my knowledge and belief, true, correct
and complete.
Signature of surviving spouse, etc., having personal knowledge of the foregoing Date
Signature of executor or administrator (or person with actual or constructive possession) Date
Mail to: Massachusetts Department of Revenue, Bureau of Desk Audit, Estate Tax Unit, PO Box 7023, Boston MA 02204.
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