Washington Affidavit Substantiating Decedent’s State of Domicile at Death

Affidavit Substantiating Decedent’s State of Domicile at Death
Affidavit Substantiating Decedent’s State of Domicile at Death
Affidavit Substantiating Decedent’s State of Domicile at Death

Affidavit Substantiating Decedent’s State of
Domicile at Death

Form 85 0045
Audit Division
Estate Tax Unit
PO Box 47474
Olympia WA 98504-7474
360-704-5906

Washington State Department of Revenue will use this affidavit to help
determine the state of residency of a decedent when the state of domicile
is in dispute. This affidavit should be sworn to by a person having personal
knowledge of the facts (for example, surviving spouse, member of
immediate family, personal representative, etc.).

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First name of decedent:

Middle:

Date of death:

Last:

	 Social Security number:

1.	 Decedent’s primary residence at the date of death:
City	:
State:
Zip Code:
Country:
Decedent’s mailing address at the date of death:
City	:
State:
Zip Code:
How long at this location?	
To the best of your knowledge, what state did the decedent intend to reside in until the date of his/her death? 	

Yes

2.	 Did decedent reside in a nursing home in Washington (WA) at date of death?
Length of stay:
Circumstances warranting stay:

Yes

3.	 Did decedent own a home(s)?

No

No. 	 If yes, give city and state:
Yes

Is the home currently being rented or leased?

Yes

Is the home available for rent or lease?

No	

No

4.	 On date of death, did decedent own real property, leasehold, or tangible personal
property located in WA? 	

Yes

No

5.	 Was decedent employed in WA during the last five years prior to death?

Yes

No

6.	 Was decedent engaged in operating a business in Washington during the last five
years prior to death?
Yes
No
Did decedent own any part of the business?
Describe decedent’s participation:

Yes

No

7.	 Location of IRS Service center the decedent’s last federal income tax return was filed prior to death:
City	:

State:

On what date?

Street address shown on return:

State:

8.	 Did decedent own or lease a motor vehicle(s)?
If yes, in what states were they registered?	
9.	 Was decedent registered to vote?

Yes

Yes

Zip:

No

No If yes, in what state were they registered?

10.	 Did the decedent hold a driver’s license at date of death?

Yes

No

If yes, what state?	

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REV 85 0045 (9/3/21)				

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Affidavit Substantiating Decedent’s State of Domicile at Death
Yes

11.	 Did decedent hold any other types of licenses or permits at date of death?

No

If yes, list types and which states they were issued from:
12.	 Did decedent hold membership in any community or religious organizations, clubs or societies in Washington
within the last five years?

Yes

No	

If yes, list:

Yes

13.	 Did decedent rent any safe deposit boxes in Washington at date of death?
14.	 Did decedent visit Washington within five years prior to the date of death?
If yes, please list location, date and reason for each visit:

Location

Date

No

Yes

No

Reason

15.	 Did the decedent declare a state of residence near the date of death?

Yes

No

Which state?
To whom was this declaration made? First:

Last:

What was the approximate date of the declaration?
16.	 If out-of-state domicile is claimed, state any additional facts relied upon to support this claim.

Notarized signature

I, the undersigned, reside at ________________________________________________________________________
My relationship to the decedent is ___________________. The above information is submitted under penalty of
perjury in support of the statement that the above decedent was domiciled in the State of _____________________,
city of_______________________________, at the date of death. 	 Phone: _________________ Ext:__________
Affidavit Preparer: X______________________________	

Date _______/_______/_______

State of ___________________, County of _______________________________.	
I certify that I know or have satisfactory evidence that	 (name of person): _______________________________
is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument and
acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument
Dated: ______/______/_____			
Signature of Notary Public:________________________
	

(SEAL OR STAMP)

Residing at: ____________________________________
Notary Public in and for the State of: _______________

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REV 85 0045 (9/3/21)				

My appointment expires: _______/________
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