REV-1737-1 - Nonresident Decedent Affidavit of Domicile
EX (03-15)
OFFICIAL USE ONLY
NONRESIDENT DECEDENT
AFFIDAVIT OF DOMICILE
ENTER DECEDENT INFORMATION BELOW
REV-1737-1
Bureau of Individual Taxes
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.
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.
1. 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
2. Did the decedent ever live in Pennsylvania?
o
Yes
o
No
If yes, during what periods
?
3. Did the decedent spend time in Pennsylvania during the five years preceding death ?
o
Yes
o
No
If yes, during what periods and at what address(es)?
4. 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.
County Code Year File Number
Decedent’s Name (Last, First and Middle Initial)
First Line of Address
Social Security Number
MMDDYYYY
Date of Death
Date of Birth
MMDDYYYY
Second Line of Address
City or Post Office State ZIP Code
SIDE 1
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