Free affidavit of domicile 43Free affidavit of domicile 43
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State of Washington
Department of Revenue
Special Programs Division

AFFIDAVIT SUBSTANTIATING
DECEDENT’S STATE OF DOMICILE AT DEATH

Miscellaneous Tax
PO Box 47477
Olympia WA 98504-7477

The following affidavit will be used by the Washington State Department of Revenue 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 (i.e., surviving spouse, member of immediate family, personal representative, etc.).
Name of Decedent
Date of Death

First

/

Middle

Last

/

1. Where was the decedent’s primary residence at the date of death? (city, state, country)
What was decedent’s mailing address at the date of death?
Street Address
City

State

How long at this location?

Zip Code

To the best of your knowledge, what state did the decedent intend to reside

in until the date of his/her death?
2. Did decedent reside in a nursing home in Washington at date of death?  Y