BETTY T. YEE 

                                California State Controller 

                    DECLARATION CONCERNING RESIDENCE 

   Name of Decedent              Social Security Number                              Date of Death 

The State Controller’s Office requires this form to be completed for the purposes of establishing 
residency for the decedent.  These questions are in accordance with the Estate Tax Regulations, 
section 1138.29 (Evidence of Intent). This document must also be completed if the decedent was not 
a California resident and had real or tangible personal property located in California.  The 
undersigned, under penalty of perjury, makes the following statements: 

1. What was the decedent’s legal residence at the date of death?                     (full address) 

   a. Decedent’s street address:

   b. Type of abode maintained at that address  (home, apartment, hotel room, etc.)

   c  How long did the decedent reside in Californoia in the year when he/she passed away? 

2. Where was the decedent’s physical residence at the date of death?                 (City and state or country)

3. Did the decedent own a home?       Yes     No If yes, give city and state. 

4. When and where was the decedent last employed or actively engaged in business?

5. When and where did the decedent last vote?

                                             MAILING ADDRESS 
                                     Local Government Programs and Services Division 
                                     P.O. Box 942850, Sacramento, CA 94250 
                                     3301 C Street, Suite 700, Sacramento, CA 95816 

6. For what year did the decedent last file a federal income tax return?

7. In which state and county did the decedent last file a state income tax return?

8. Did the decedent own an automobile?  Yes            No .If yes, in which state was it registered?

9. Did the decedent belong to a church, lodge, or other social fraternal or religious club or organization
   in California?          Yes      No.  If yes, give name and addresses of such clubs or organizations.

10. Did the decedent spend any time in California in the five years immediately prior to his/her death?
        Yes   No.  If yes, give the approximate dates, addresses, and purpose for beinginCalifornia.  

11. Use the following space to give any additional information in your possession bearing upon the
   questions of the decedent’s residence at the date of death.

To the best of my knowledge, I declare, under penalty of perjury, that all the foregoing is true and 
correct. 

(print or type) 
Executor’s/Trustee’s Name: 

Address: 

Signature: 

Date: 

Relationship to decedent: 

Note: Declaration must be notarized if signed outside the State of California. (Rev. 04/2018)