Affidavit Of Domicile
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1AFFIDAVIT OF DOMICILE
________________________)
STATE OF
)SS:
______________________)
COUNTY OF
_______________________________________________, being duly
sworn deposes and says that he/she resides at
___________________________________________________________,
State of _____________________________ and is executor/administrator of
the estate of ____________________________________ deceased, who
died on the __________ day of______________ 20_______; at the time of
his/her death the domicile (legal residence) of said decedent was
_________________________________________________________,
(address)
County of ________________________________, State of
__________________________ for _______ years prior to death, and was
not a resident of any other State (other than that of his/her domicile) within
the United States of America, at the time of death.
This affidavit is made for the purpose of securing the transfer or delivery of
securities registered in the name of or owned by said decedent at the time of
his/her death.
_____________________________________________
(EXECUTOR/ADMINISTRATOR/SURVIVOR/HEIR)
Subscribed and sworn to before me
this ______ day of ___________, 20______
___________________________________
(NOTARY PUBLIC)
My commission Expires _______________
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