EX (03-15)
                                                                           OFFICIAL USE ONLY
                  REV-1737-1
                  Bureau of Individual TaxesNONRESIDENT DECEDENT
                  PO BOX 280601             AFFIDAVIT OF DOMICILE
                  Harrisburg, PA 17128-0601                                County Code          Year      File Number
 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.
 ENTER DECEDENT INFORMATION BELOW
START Decedent’s Name (Last, First and Middle Initial)                     Social Security Number
Ü
 Date of DeathMMDDYYYYMM/DD/YYYY     Date of BirthMMDDYYYYMM/DD/YYYY

 First Line of Address

 Second Line of Address

 City or Post Office                                                                                      State              ZIP Code

 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? oYes                                       o No
      If yes, during what periods?

 3.      Did the decedent spend time in Pennsylvania during the five years precedingo death ?Yeso 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. 

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            REV-1737-1 EX
                                                                             Social Security Number

    Decedent’s Name:
5.  Was the decedent employed during the five years preceding death?Yes           o              o No
   If yes, list the name(s) and address(es) of employer(s).

6.  Did the decedent leave a will?                                                oYes           o No
   If yes, state the court that admitted the will to probate and the date admitted, and attach a copy (including all codicils) and a certificate of
   issuance of letters testamentary.

7.  If the decedent did not leave a will, has an administrator of the estate been appointed?Yeso o No
   If yes, state the court that appointed the administrator and the date of appointment, and attach a certificate of the issuance of letters of
   administration.

8.  At any time during the last five years did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease or any
   other document in which the decedent was described as a resident of Pennsylvania?Yeso         o No
   If yes, describe such document.

9.  Did the decedent pay a tax on income or on intangible property to any state, county or municipality during the last 
   five years?                                                                    oYes           o No
   If yes, where and when was it paid?

10. To what regional office of the Internal Revenue Service did the decedent forward his federal income tax returns during the 
   last five years preceding death?

11. At the time of death, did the decedent own, individually or jointly, any interest in real property, including lease-holds, or 
   tangible personal property located in Pennsylvania?Yes                         o              o No
   If yes, describe the property in detail.

12. In what business activities was the decedent engaged during the last five years preceding death?
   Indicate whether decedent was employed or otherwise engaged in the business, and state the names and the addresses of the persons,
   firms or corporations with which the decedent had such business affiliations (Except for employer listed in #5). 

13. What is the estimated gross value of the decedent’s estate, exclusive of real property and tangible property located outside 
   of Pennsylvania?

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                                                                         Social Security Number

    Decedent’s Name:
14. At the time of death, did the decedent own or operate an automobile?Yes  o             o No
If yes, in which state was it registered?

15. At the time of death, was the decedent a member of a church or any other organizationo ?Yeso No
If yes, provide the name and address of the church or any other organization.

16. State the purpose or reason the decedent owned real property in Pennsylvania.

17. Include any other information you wish to submit in support of the contention that the individual was not domiciled 
in Pennsylvania at the time of death.If more space is needed, use additional sheets of paper of same size.

Name of Person Completing Affidavit (Last, First and Middle Initial)Relationship to Decedent

Address

City or Post Office                                                                                      State ZIP Code

Under penalties of perjury, I declare that based on my personal knowledge of the decedent, the information 
provided on this form is true, correct and complete.
Signature of Person Completing Affidavit                                 MM/DD/YYYY                            Date
    Signature of person completing affidavit. Please sign after printing.

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