State of Washington
Department of Revenue
Special Programs Division
DECEDENT’S STATE OF DOMICILE AT DEATH
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
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?
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?
2. Did decedent reside in a nursing home in Washington at date of death? Y